Video-assisted thoracic surgery for primary spontaneous pneumothorax in children: is there an optimal technique?

Objective

Video-assisted thoracic surgery (VATS) for treatment of spontaneous pneumothorax refractory to nonoperative management was first reported in children by Rodgers in 1986 (Ann Surg. 1986; 204:677-680). Small series have shown success with apical blebectomy, mechanical or chemical (talc) pleurodesis, or combination techniques. We report the largest pediatric series of VATS for primary spontaneous pneumothorax (PSP) to date, to assess outcomes and compare techniques.

Methods

Retrospective review of all children undergoing VATS for PSP between 1999 and 2007 at 2 university-affiliated hospitals by the same group of surgeons. Mann-Whitney U tests and χ² used (P < .05 = significant).

Results

Thirty-two patients underwent 41 VATS procedures (32 initial-30 unilateral, 2 bilateral; 9 subsequent-7 contralateral, 2 ipsilateral recurrences). Mean age at presentation was 16.5 years (range, 13-20 years). Blebs were identified at the time of VATS in 95% of patients, but in 12.5%, they were on lower lobes. Mean duration of postoperative air leak was 2.7 days, postoperative hospital length of stay was 5.0 days, and postoperative chest tube duration was 5.1 days; 2 patients required Heimlich valves, which were managed at home. Five different surgical techniques were used as follows: blebectomy plus mechanical pleurodesis had the shortest length of stay (4.3 days) and need for chest tube drainage (4.1 days) but had a higher recurrence risk (6% major, 16% minor) than blebectomy plus chemical pleurodesis. The risk of requiring an additional VATS procedure (ipsilateral or contralateral) was 28%. Mean follow-up was 46 months.

Conclusions

Blebectomy plus either mechanical or chemical pleurodesis were both associated with acceptable outcomes. Blebectomy plus chemical pleurodesis appears to have less risk of ipsilateral recurrence but longer postoperative stay and chest tube drainage.     

Thoracoscopic parietal pleural argon beam coagulation versus pleural abrasion in the treatment of primary spontaneous pneumothorax.

OBJECTIVE: The obliteration of pleural space is useful to prevent recurrences of spontaneous pneumothorax. We retrospectively compared the results of pleural argon beam coagulation versus pleural abrasion in the treatment of primary spontaneous pneumothorax. METHODS: Between 1996 and 2004, 136 patients underwent surgery for primary spontaneous pneumothorax, with 143 surgical procedures, all performed by VATS. Indications were recurrent pneumothorax in 107 patients, a complicated first episode in 29 and occupational activity in 7. Six patients were excluded because of postoperative histopathological diagnosis other than pulmonary emphysema. In 70 cases pleurodesis was performed with argon beam coagulation and in 67 by Marlex degrees mesh abrasion. These techniques were employed during two different periods. Median follow-up was 68 months in the Marlex degrees group and 41 in the argon group. The two groups resulted as being homogeneous for gender, age, smoking attitude and surgical indication. Statistical analysis was done with chi2 and Fisher's test. RESULTS: No postoperative mortality was observed. Mean recovery time was 5 days. There were three patients with postoperative bleeding who underwent re-operation. There were nine cases of prolonged air-leak, one needing surgical exploration. Nine recurrences were noted, all requiring surgery. Two recurrences were observed in the group treated by pleural abrasion (3.4%) and seven in the group treated by argon coagulation (10.7%). The Fisher's test failed to demonstrate a statistical significance between the two procedures in terms of recurrence rate (p=0.18). Multivariate analysis yielded no risk factors for recurrences. Postoperative complications resulted as being equally distributed in both groups. CONCLUSION: After primary spontaneous pneumothorax, pleurodesis induced by argon beam parietal pleural coagulation resulted as being no better than that obtained by pleural abrasion in the prevention of recurrences. No benefits in terms of postoperative complications resulted by use argon beam coagulation.     

Primary spontaneous pneumothorax: one-stage treatment by bilateral videothoracoscopy

BACKGROUND: The goal of the study was to report our 7-year experience with single-stage bilateral videothoracoscopy for bleb excision and pleural abrasion in patients suffering primary spontaneous pneumothorax. METHODS: From November 1992 through June 1999, 12 men were operated on in our department. Preoperative chest computed tomographic scans were obtained for all patients. Operative indications included simultaneous bilateral pneumothorax (n = 2), contralateral recurrence (n = 1), ipsilateral recurrence with contralateral blebs or bullae, and job restrictions (n = 9). RESULTS: Mean age at operation was 26+/-6 years. All patients had multiple blebs or bullae located in upper lobes, and 4 patients (33%) had pleural adhesions. All blebs or bullae were resected at operation. The mean number of staple cartridges was 5 per patient (range, 3 to 8). All patients had bilateral pleurabrasion. There were no perioperative complications and no conversion to thoracotomy. The mean operative time was 168+/-17 minutes (range, 140 to 190 minutes). The mean drainage time was 5 days (range, 4 to 26 days) and the mean hospital stay was 7.7+/-1.4 days for 11 of 12 patients. Postoperative complications included prolonged air leak (16.5%), incomplete lung reexpansion (25%), and pleural effusion (8.5%). One patient required reoperation on the right side through transaxillary thoracotomy within 1 month of videothoracoscopy for pleurodesis failure. Follow-up was 100% complete. Mean follow-up is 50+/-34 months (range, 9 to 88 months) and no patient has had recurrence of pneumothorax. All patients except one returned to full occupational activity within 5 weeks of surgery. CONCLUSIONS: Single-stage bilateral videothoracoscopy for bilateral bleb excision and pleurabrasion is a safe procedure that does not result in major complications and provides excellent long-term results. This approach could be considered in young patients with bilateral primary spontaneous pneumothorax, or in those requiring radical therapy for the prevention of ipsilateral and contralateral recurrences.     

Treatment of complicated spontaneous pneumothorax by simple talc pleurodesis under thoracoscopy and local anaesthesia

BACKGROUND: Complicated (recurring or persistent) spontaneous pneumothorax requires treatment either by talc pleurodesis with bullae electrocoagulation or, more aggressively, by thoracotomy or video- assisted thoracoscopic surgery. However, the relative merits of bullectomy, pleurectomy, and pleurodesis have not yet been established in the treatment of spontaneous pneumothorax. METHODS: The complications, duration of drainage, length of hospital stay, and immediate and long term success rate of treating complicated spontaneous pneumothorax with talc pleurodesis under local anaesthesia supplemented with nitrous oxide were studied. RESULTS: Talc pleurodesis was performed in 93 patients without serious complication (two benign arrhythmias, two subcutaneous emphysema, two pneumonia, one bronchospasm). The procedure was immediately successful in 90 patients (97%) with a median duration of drainage of five days (range 2-40) and a median length of hospital stay of 5.2 days (range 3-40). After a mean follow up duration of 5.1 (range 1-9.4) years in 84 cases the long term success rate was 95%, although six cases developed a small localised recurrence of spontaneous pneumothorax which did not require further surgery. Macroscopic staging at thoracoscopy was only carried out in the last 59 cases of whom 10 (17%) had bullae with a diameter of > 2 cm. In this group of patients the risk of definitive failure requiring surgery was significantly higher than in those patients without such bullae (odds ratio 7; confidence interval 3.7 to 13.3; p = 0.03), although eight of these patients did not require thoracotomy. Total lung capacity was reduced immediately after talc pleurodesis (mean (SD) 75 (23)% predicted at 10 days) but had improved to 95 (14)% predicted at 12 months. CONCLUSIONS: This study shows that simple thoracoscopic talc pleurodesis under local anaesthesia is a safe and effective treatment for complicated spontaneous pneumothorax. However, patients with bullae of > 2 cm in diameter have a greater risk of treatment failure.


     

Video-assisted thoracic surgery in the treatment of spontaneous pneumothorax

BACKGROUND: The aim of this study was to evaluate the surgical indications and the results of a series of 107 patients treated by video-assisted thoracic surgery for spontaneous pneumothorax with a minimum follow-up of 12 months. METHODS: From January 1991 to December 1997, 107 patients (86 male and 21 female patients) mean age 28 years (range 14-78), underwent VATS for treatment of spontaneous pneumothorax. RESULTS: Seventy-five patients had primary spontaneous pneumothorax (PSP) and thirty-two patients had secondary spontaneous pneumothorax (SSP). Bullous area was not seen in 26 patients with PSP. Ninety-nine patients were treated with wedge stapled resection of the bullous area or of the apex (when no bullous area was seen) and some form of pleurodesis, whereas 8 patients with PSP were treated only with pleurodesis. Among these 8 patients, two presented recurrence. Two patients with PSP and 8 patients with SSP were treated by apical pleurectomy: no one developed recurrence. The other 97 were treated with electrocoagulation of the parietal pleura. Conversion to a thoracotomy was necessary in 4 patients (12.5%) because of massive pleural adhesions. There were no postoperative deaths. A complication developed in 3 patients (4%) with PSP and in 5 patients (17.8%) with SSP, whose procedure was ended by VATS. The duration of systematic postoperative drainage was 3.8 +/- 0.9 (range 3-15 days) for the group of patients with PSP and 6 +/- 2.1 (range 4-23 days) for the group of patients with SSP. The duration of the hospital stay was 5.6 +/- 1.4 (range 4-15) and 8.4 +/- 2.3 (range 6-18) in patients with PSP and SSP respectively. Follow-up analysis revealed 2 (2.66%) ipsilateral recurrent pneumothorax in 75 patients treated for PSP. Among 26 patients with SSP, whose procedure was completed by VATS, 2 recurrences (7.7%) were observed. CONCLUSIONS: Surgical treatment by VATS is a valid alternative to open thoracotomy in patients with PSP and will be the treatment of choice because, with increased experience of surgeons, it will yield the same results as standard operative therapy but with the advantages of the minimally invasive operation. The usefulness of VATS in patients with SSP remains to be defined.     

Comparative study of talc poudrage versus pleural abrasion for the treatment of primary spontaneous pneumothorax

Primary spontaneous pneumothorax is a pathology mainly affecting healthy young patients. Clinical guidelines do not specify the type of pleurodesis that should be conducted, due to the lack of comparative studies on the different techniques. The aim of this study was to compare talc poudrage and pleural abrasion in the treatment of spontaneous pneumothorax. A retrospective comparative study was performed, including 787 patients with primary spontaneous pneumothorax. The 787 patients were classified into two groups: Group A (pleural abrasion) n = 399 and Group B (talc pleurodesis) n = 388. The variables studied were recurrence, surgical time, morbidity and in-hospital length of stay. Statistical analysis was done by an unpaired t-test and Fisher's exact test (SSPS 18.0). Statistically significant differences were observed in the variables: surgical time (A: 46 ± 12.3; B: 37 ± 11.8 min; P < 0.001); length of stay (A: 4.7 ± 2.5; B: 4.3 ± 1.8 days; P = 0.01); apical air camera (A: 25; B: 4; P < 0.001); pleural effusion (A: 6; B: 0; P = 0.05). Talc poudrage shows shorter surgical times and length of stay, and lower re-intervention rates. Morbidity is lower in patients with talc poudrage. Statistically significant differences were not observed in recurrence, persistent air leaks, atelectasis and haemothorax.     

Pleurodesis in spontaneous pneumothorax by means of tetracycline. Follow-up evaluation of a method

The validity of previous recommendation of early thoracoscopy and tetracycline pleurodesis in the management of spontaneous pneumothorax without thoracoscopically visualized true cyst was assessed under non-trial, normal hospital conditions. Among 46 patients treated during a year, seven underwent immediate thoracotomy following finding of large cysts. Of the remaining 39 patients, 11 had recurrence of pneumothorax after a median of 11 (range 2-64) weeks. Repeat thoracoscopy then showed large cyst or bullous emphysema in seven cases. Tetracycline pleurodesis was again performed in the others. In continued observation for at least 2 years there were no further recurrences. The importance of meticulous thoracoscopy is stressed. The demonstrated diagnostic errors do not detract from the value of tetracycline pleurodesis when spontaneous pneumothorax is caused by rupture of only tiny blebs on the surface of an otherwise healthy lung. The procedure is fast, simple and efficacious.     

Impact of additional pleurodesis in video-assisted thoracoscopic bullectomy for primary spontaneous pneumothorax

BACKGROUND: Bullectomy for primary spontaneous pneumothorax has been associated with high postoperative recurrence rates when video-assisted thoracoscopic surgery (VATS) has been used rather than thoracotomy. The aim of this study was to evaluate the efficacy and identify the disadvantages, if any, of adding pleurodesis to VATS bullectomy to prevent recurrent pneumothorax. METHODS: Fifty-three patients who underwent VATS bullectomy with additional pleurodesis for pneumothorax after November 1996 and 50 who underwent VATS bullectomy alone before October 1996 were compared retrospectively in terms of intraoperative factors and postoperative chest pain, pulmonary function, and pneumothorax recurrent rates. Pleurodesis was achieved by electrocauterizing the upper surface of the parietal pleura in a patchy fashion. RESULTS: There were no significant differences between the additional pleurodesis group and the bullectomy alone group in terms of age, sex, operating time, intraoperative bleeding, number of resected bullae, duration of chest drainage, or volume of fluid drained. Postoperative chest pain and pulmonary function were also similar in both groups. A recurrent pneumothorax occurred in one patient (1.9%) in the additional pleurodesis group; this recurrence rate was significantly lower than that for the bullectomy alone group (eight patients, 16%; p = 0.029). Although the mean postoperative follow-up period was considerably shorter in the additional pleurodesis group (38 months [range, 26-49]) than in the bullectomy alone group (63 months [range, 50-72] ), eight (89%) of all nine recurrences occurred within 26 months of surgery-i.e., within the minimum follow-up period for the additional pleurodesis group. CONCLUSIONS: Pleurodesis is a minimally invasive technique that is effective in preventing postoperative recurrences of pneumothorax when added to VATS bullectomy. Additional pleurodesis has no disadvantages vs bullectomy alone in terms of worsening postoperative chest pain or pulmonary function.     

Experience with thoracoscopic pleurodesis in the treatment of idiopathic spontaneous pneumothorax

Between January 1987 and December 1988 thoracoscopic pleurodesis has been used as a standard treatment for idiopathic spontaneous pneumothorax. Bullae were electrocoagulated, and visceral and parietal pleurae were cauterized. Chemical pleurodesis with 50% glucose-solution was added. 34 procedures were performed on 32 patients. The average hospital stay was 8 +/- 2 days. One patient suffered from postoperative Horner-syndrome. No other complications occurred. Patients were re-evaluated 11 +/- 8 months after the operation. Recurrence was found in four patients within 30 days. These patients underwent pleurectomy. Another patient had recurrence after two months. He was again and successfully treated by thoracoscopic pleurodesis. Our data show improvement of the results as compared with simple chemical pleurodesis.     

电视胸腔镜处理自发性气胸疗效分析

目的　评价电视胸腔镜 (VATS)处理自发性气胸的疗效。　方法　将手术治疗的自发性气胸分为VATS组和剖胸组 ,按原发性和继发性进行术中术后各种参数的回顾性分析。　结果　与剖胸组相比 ,VATS组在术中出血量、手术时间及术后住院时间方面明显优于对照组。VATS组和剖胸组术后并发症发生率分别为 8.4%和 2 0 .9% (P <0 .0 5 ) ,近期漏气率分别为 5 .6%和 7% (P >0 .0 5 ) ,远期复发率分别为 2 .8%和 2 .3% (P >0 .0 5 )。　结论　与剖胸术比较 ,VATS更易被病人接受 ,总的疗效较优 ,应作为自发性气胸的首选治疗方法     

Silver nitrate pleurodesis in spontaneous pneumothorax

Pleurodesis provoked by instillation of silver nitrate as prevention against recurrence in primary spontaneous pneumothorax has been used for many years in the Department of Thoracic Surgery, Gentofte Hospital, University of Copenhagen. The treatment was originally instituted on a theoretical empiric basis. In a prospective, controlled investigation of pleurodesis versus simple drainage the empiric observations have been confirmed. With simple drainage we found ipsilateral recurrence of pneumothorax in 45%, while no recurrences in the pleurodesis group were found during an observation period of 5-19 months. The difference was statistically significant. The therapeutical gain using pleurodesis was 45% +/- 30%. Silver nitrate pleurodesis results in a longer hospitalization, raises the number of pleurocentesis because of increased pleural effusion and results in more pain than simple drainage. It is, however, our experience that the considerable therapeutical gain more than compensates for these negative effects. We recommend pleurodesis as the treatment of choice in primary spontaneous pneumothorax in patients with only tiny blebs on the surface of the lungs.     

Mechanical versus chemical pleurodesis for management of primary spontaneous pneumothorax evaluated with thoracic echography

The current study is designed to compare the effectiveness of brushing the pleura vs. instillation of minocycline for the management of primary spontaneous pneumothorax, and to assess the sensitivity of echography in defining areas of defects. Blebectomy and pleurodesis were carried out thoracoscopically on 84 patients. In group A (42 patients), abrasions were induced using a sponge on a long ring forceps. Group B (42 patients) received intrapleural instillation of minocycline. Echography was carried out two weeks after discharge and then repeated two weeks later. Follow-up ranged between 28 and 39 months. Two patients were excluded from group A for incomplete follow-up. In group A, five patients (12%) showed areas of free mobility of the lung on first echography. At the second examination, three (7% of the total) showed the same areas of mobility; one patient developed an attack of localized pneumothorax after 32 and another after 45 weeks. Each had three adjacent areas of free mobility. In group B, two patients each showed one area of free mobility on the first and second examinations but no recurrence during follow-up. The two groups had comparable chest drainage, postoperative hospital stay and complication rates. The patients in group B demonstrated a trend towards a decreased rate of prolonged air leaks (2% vs. 5%; P=0.100). Thus, pleurodesis by instillation of minocycline as a part of thoracoscopy is more effective than brushing the pleura. Thoracic echography is a highly sensitive method for assessing the effectiveness of pleurodesis.     

Spontaneous pneumothorax: comparison of simple drainage, talc pleurodesis, and tetracycline pleurodesis.

From 1978 to 1985 96 patients with their first spontaneous pneumothorax were randomised into three groups, receiving either treatment with simple drainage (34 patients), drainage with tetracycline pleurodesis (33 patients), or drainage with talc pleurodesis (29 patients). There were 58 men and 38 women, aged 18-88 years. There was no significant difference between the three groups in the mean time in hospital or the period for which the drains were retained. The incidence of infection, persistent pneumothorax, and relapse while in hospital was also similar for the three groups. At follow-up in 1987-89 patients could be accounted for, with an average follow-up period of 4.6 years. The incidence of recurrence was 36% in the simple drainage group, 13% in the tetracycline pleurodesis group, and 8% in the talc pleurodesis group. The difference between the talc and simple drainage groups was significant. None of the methods caused severe short or long term side effects or changes in the follow-up chest radiograph. Thoracoscopy, performed on admission in 85 patients, showed normal appearances in 73 patients and small cysts in 12. The thoracoscopic findings were of no value in predicting recurrence. Talc pleurodesis resulted in a significantly lower recurrence rate than simple drainage, tetracycline pleurodesis having intermediate efficacy.     

Stapler blebectomy and pleural abrasion by video-assisted thoracoscopy for spontaneous pneumothorax

BACKGROUND: This study aims to evaluate the efficacy of video-assisted thoracoscopic surgery (VATS) pleurodesis in the treatment of spontaneous pneumothorax with particular reference to the postoperative period and the rate of recurrence after pleural abrasion. METHODS: One hundred and thirty-three patients who underwent VATS management of primary spontaneous pneumothorax were retrospectively reviewed. They were 113 males and 20 females with median age of 26 (range 12-37). Among these patients, 114 underwent VATS for recurrent pneumothorax and 19 for persistent air-leakage at the first episode. During surgical procedure, in 78% of cases, parenchymal blebs were identified and resected by stapler resection. All patients were submitted to pleural abrasion. RESULTS: No intra- or postoperative deaths occurred. Postoperative complications were persistent air-leak for more than 7 days in 6 patients (4.3%) bleeding in 3 patients (2.2%). The median chest-tube duration and hospital stay were 2 (range 2-11) and 3 (range 3-12) days, respectively. Median follow-up period of 53 (range 6-96) months was complete for all patients. Five episodes of recurrent pneumothorax were encountered and 4 of them, because of major entity, required re-do VATS with stapler resection and pleural abrasion: their postoperative period and residual follow-up was uneventful. CONCLUSIONS: The goal in the surgical management of spontaneous pneumothorax, which often affects "apparently healthy" young patients, is to secure the less recurrence rate with no mortality and quite null morbidity and functional impairment. VATS stapler resection and pleural abrasion is a safe procedure allowing a good management of the disease with low complication rate, short chest-drain duration, hospital stay and recurrence rate quite similar to those referred for other procedures such as pleural poudrage or limited pleurectomy.     

Long-term results after tetracycline pleurodesis in spontaneous pneumothorax.

From 1979 to 1988 483 patients were admitted with primary spontaneous pneumothorax. All patients underwent thoracoscopy to identify the cause of pneumothorax. Chemical pleurodesis with instillation of tetracycline was performed if cysts less than 2 cm in diameter were found. If larger cysts were identified the patient underwent thoracotomy. In 93 patients with cysts larger than 2 cm the recurrence rate after thoracotomy was 4%. In 390 patients treated with intrapleural instillation of tetracycline, the recurrence rate was 16%. Fifty percent of the recurrences occurred within 30 days. The cause of recurrence in 42 patients (69%) was cysts missed at the initial thoracoscopy. This study has demonstrated that thoracoscopy is a reliable and safe method for selection of patients for chemical pleurodesis. It is, however, necessary that the thoracoscopy is meticulous to avoid recurrence from missed cysts.     

A cost-effective thoracoscopic treatment strategy for pediatric spontaneous pneumothorax

Background: Recent data suggest that children have a higher incidence of recurrence than adults after nonoperative treatment of primary spontaneous pneumothorax (PSP). Video-assisted thoracoscopic surgery (VATS) allows efficacious therapy with significantly less morbidity. We attempt to define the most cost-effective clinically efficacious strategy using VATS to manage pediatric PSP. Methods: We retrospectively reviewed all admissions to a tertiary care children's hospital for PSP between January 1, 1991 and June 30, 1996. Results: Fifteen children had 29 primary or recurrent PSPs. Mean patient age was 14.8 ± 1.1 years, boy–girl ratio 4:1, median body mass index 18 (normal, 20–25), and 67% of pneumothoraces left sided. All patients were managed initially nonoperatively: 14 with tube thoracostomy drainage and 1 with oxygen alone. Of the children initially managed nonoperatively, 57% had a recurrent pneumothorax, and 50% of these patients eventually developed contralateral pneumothoraces. Nonoperative treatment for recurrence resulted in a 75% second recurrence rate. In contrast, eight children who underwent operative management had a 9% incidence of recurrence. The total for charges accrued in treating 29 pneumothoraces in these 15 patients was approximately $315,000. In the same population, the estimated charges for initial nonoperative therapy followed by bilateral thoracoscopy after a single recurrence would be $230,000. Conclusions: A cost-effective treatment strategy for pediatric primary spontaneous pneumothorax is tube thoracostomy at first presentation, followed by VATS with thoracoscopic bleb resection and pleurodesis for patients who experience recurrent pneumothorax. Received: 15 May 1998/Accepted: 15 January 1999     

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.     

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.     

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.     

Efficacy study of video-assisted thoracoscopic surgery pleurodesis for spontaneous pneumothorax

BACKGROUND: This study aims to assess the efficacy of video-assisted thoracoscopic surgery pleurodesis in the treatment of spontaneous pneumothorax with particular reference to the rate of recurrence after abrasion pleurodesis and postoperative neuralgia. METHODS: One hundred one patients who underwent 109 video-assisted thoracoscopic surgery pleurodesis procedures in the Austin & Repatriation Medical Centre between January 1992 and June 1998 were identified from a computerized database. The follow-up period was from 8 months to 7 years and 1 month (mean, 44.4 months). Patients were telephoned and asked as to whether recurrence occurred, and if so, when it occurred and how it was treated. They were asked to grade their current pain level from 0 to 6. RESULTS: Eighty-two patients were contacted, corresponding to 88 video-assisted thoracoscopic surgery pleurodesis procedures that were followed up (80.7%). There were five recurrences (5.7%). The pain level was rated as 0 in 64 cases (72.7%), 1 in 27 cases (23.9%), 2 in 1 case (1.1%), and 3 in 2 cases (2.3%). CONCLUSIONS: These data suggest that video-assisted thoracoscopic surgery pleurodesis is a valid alternative to thoracotomy with pleurectomy for treatment of spontaneous pneumothorax with an acceptable recurrence rate and minimal amount of postoperative neuralgia.