Videothoracoscopic surgical approach for spontaneous pneumothorax: review of the pertinent literature

Spontaneous pneumothorax is usually caused by the rupture of subpleural blebs/bullae in the underlying lung and is one of the most common elective applications of video-assisted thoracoscopic surgery (VATS). VATS has been used as an alternative to thoracotomy in the treatment of spontaneous pneumothorax. Recurrent pneumothorax and persistent air leakage are quite often indications for spontaneous pneumothorax, and bilateral spontaneous pneumothorax is also considered to be an indication for surgical intervention. The goals of surgical intervention are to eliminate intrapleural air collection and prevent recurrence. Diverse procedures have been reported in the surgical treatment for spontaneous pneumothorax. We review the literature regarding the VATS approach for spontaneous pneumothorax.     

Latest treatments for spontaneous pneumothorax

Objective  

Currently, the treatment of pneumothorax varies among hospitals. Three factors account for the differences. First, pneumothorax expresses the state of disease instead of the disease itself. Some pneumothoraces heal on their own but patients with pneumothorax due to chronic diseases may need further intervention. The decision for the choice of treatment is up to the physician. Second, it is insufficient to treat pneumothorax with current treatment guidelines. Third, prognosis and follow-up after pneumothorax treatment is not well documented. Therefore, verification/assessment of treatment and its effect is insufficient.     

Optimal Timing for Surgical Treatment to Prevent Recurrence of Spontaneous Pneumothorax

Purpose Persistent air leakage and recurrence are the most common indications for the surgical treatment of spontaneous pneumothorax; however, the optimal timing for surgery is still unclear. Methods The subjects of this study were 90 patients treated for either primary spontaneous pneumothorax (PSP; n = 58) or secondary spontaneous pneumothorax (SSP; n = 32). We compared the incidence of prolonged air leak, the rate of recurrence of pneumothorax, the time from the first episode of pneumothorax to recurrence, and the postoperative complications in the two groups. We also analyzed the recurrence rate after treatment with observation and tube drainage versus surgery. Results Seventy-three patients were treated with tube thoracostomy or oxygen therapy for the first episode of pneumothorax. Surgery was performed in 32 patients; for the first episode of pneumothorax in 17 and for the second or third episode in 15. Postoperative complications developed in six (18.7%) patients and 24 of 73 patients who did not undergo thoracotomy suffered recurrence. The incidence of a second episode was 32.9% and the incidence of a third episode in the 18 patients who suffered recurrence after conservative treatment was 61.1%. None of the patients who underwent surgery suffered recurrence. Conclusions Tube thoracostomy is still the treatment of choice for first-time spontaneous pneumothorax. However, because the incidence of a third episode of pneumothorax after conservative treatment is high, surgical treatment should always be considered for patients with recurrence. In short, surgical intervention is safe and effective and minimizes the chance of recurrence of both PSP and SSP.     

Pneumothorax, what kind of therapy is necessary? A clinical overview

Pneumothorax is defined as the accumulation of air in the pleural space. A distinction is made between a primary (idiopathic) spontaneous pneumothorax (PSP), secondary spontaneous pneumothorax (SSP) as well as between iatrogenic pneumothorax and traumatic pneumothorax. Primary spontaneous pneumothorax (PSP) occurs mainly in otherwise healthy people (mainly tall and thin young men) without any clinical sign of lung disease. In contrast, secondary pneumothorax (SSP) mostly occurs in patients with diagnosed and clinically manifested lung disease and is most frequent in older subjects (> 50?years). Smokers have a higher risk of developing pneumothorax. Most pneumothorax cases require a therapeutic intervention using thorax drainage. Observation alone is recommended for only those few patients suffering from pneumothorax without clinical symptoms. Although simple needle aspiration is often recommended as a first-line treatment, our clinical experience shows no advantage for most of the patients. All patients with symptomatic pneumothorax should be treated with immediate intercostal tube drainage. In the surgical therapy of pneumothorax, VATS (video-assisted thoracic surgery) is the current effective standard treatment. Open posterolateral thoracotomy is the recommend approach rather than the minimally invasive procedure in patient with serious illness or complications. The aim of both interventions is to reduce the recurrence rate of pneumothorax as much as possible.     

Surgical treatment of bilateral spontaneous pneumothorax

88 cases of bacterial spontaneous pneumothorax, 20 cases, occurred same time and 68 cases, occurred different time, were treated in our Department of Thoracic Surgery from 1975 to July 1987, and represented 16.6% of all cases of spontaneous pneumothorax. The characteristics of bilateral spontaneous pneumothorax, occurred same time, were as follows; 1) frequent in teens, 2) often occurred with history of unilateral spontaneous pneumothorax, 3) slightly collapsed. For the treatment of bilateral spontaneous pneumothorax, occurred same time, bilateral thoracotomy was necessary. The characteristics of bilateral spontaneous pneumothorax, occurred different time, were as follows; 1) frequent in the twenties, 2) often occurred the other side after unilateral thoracotomy within a year. For the treatment of bilateral spontaneous pneumothorax, occurred different time, if the patient is under 20 thoracotomy must be carried out, but if the patient is over 20 at the side of pneumothorax must be operated.     

Bilateral Pneumothorax: A Retrospective Analysis of 40 Patients

Purpose To retrospectively investigate the effectiveness of tube drainage in the treatment of bilateral pneumothorax.Methods We retrospectively examined 40 patients with bilateral pneumothorax treated at the Thoracic and Cardiovascular Surgery Departments of Selcuk University between January 1994 and December 2000. There were 37 male and 3 female patients, aged 5–80 years (mean age, 42 years). The definite diagnosis of pneumothorax was made by radiological evaluation. In total, 38 tube drainage, 2 thoracentesis, and observation procedures were done, and some patients also required thoracotomy or median sternotomy.Results The types of pneumothorax were spontaneous in 9 patients, traumatic in 30, and iatrogenic in 1. We treated simultaneous bilateral pneumothorax in 34 patients and nonsimultaneous bilateral pneumothorax in 6 patients by tube drainage or additional surgical treatment. Two patients died.Conclusions Bilateral pneumothorax may require extended hospital stay and could result in death. We think that tube drainage is appropriate and effective for most cases of bilateral pneumothorax.     

Catamenial pneumothorax due to diaphragmatic endometriosis; report of a surgical case

A 27-year-old female was complained repeated right pneumothorax. Each episode was obviously related to the onset of menstruation, suggesting catamenial pneumothorax. Thoracoscope revealed the presence of several fistulas in the central tendon of the diaphragm. Partial resection of the diaphragm including these lesions was performed under thoracoscopic procedure. Microscopic examination of the excised specimen showed endometriosis. The patient was followed without hormonal therapy, but recurrent pneumothorax occurred. For the catamenial pneumothorax, hormonal treatment is considered necessary even after surgical treatment.     

支气管镜介入治疗顽固性气胸的进展

顽固性气胸是气胸治疗时的一个棘手问题,导致住院时间延长、并发症发生率和死亡率增加。外科手术因为术后复发率最低而被多个专业指南推荐作为难治性气胸的主要治疗手段,电视辅助胸腔镜由于创伤较小而被多个指南推荐作为首选的外科干预手段。但临床上部分患者因身体状况无法耐受手术,还有部分患者不愿接受手术。对于这些患者,指南不推荐行外科手术治疗,而仅建议行内科胸膜固定术。支气管镜介入治疗顽固性气胸因为较高的疗效和安全性,避免了麻醉和手术风险,已成为国内外学者多年来反复探索的重要方向,本文就相关技术进行文献综述。     

Simultaneous bilateral pneumothorax. Case report

A case report of a 44 year-old white man admitted to the surgical unit for a bilateral simultaneous pneumothorax is presented. The pneumothorax occurred on day one after a surgical operation for discal hernia; in the past the patient already presented a right spontaneous pneumothorax at 32 years of age and a left pneumothorax at 37 years of age, both treated with a pleural drainage. A thoracic drain was bilaterally positioned with a good result only in the right side. The persistence of the left pneumothorax induced the authors to perform a postero-lateral thoracotomy bullae excision and pleurectomy with a good postoperative course. After a few months a new right pneumothorax occurred and the patient was treated with a right postero-lateral thoracotomy, bullae resection and pleurectomy. On the basis of the case reported, the authors consider the different opportunities in the treatment of spontaneous pneumothorax in relation to the present knowledges and technologies. Surgical procedure is to be preferred in case of persistence of pneumothorax despite a pleural drain and in case of pneumothorax in high risk subjects. Even if thoracoscopy seems to give better results regarding postoperative pain, it is not always possible with such a method to perform a careful pleurectomy neither to obtain it in all cases (above all in secondary pneumothorax). Every case must then be carefully studied to choose the best treatment at present available.     

Pleural abrasion in the treatment of recurrent or persistent spontaneous pneumothorax. Results of 94 consecutive cases.

In the ten-year period 1982 to 1991, 94 patients underwent pleural abrasion as definite treatment for spontaneous pneumothorax. Surgical indications included: 1) third recurrence of homolateral pneumothorax, 2) second recurrence of homolateral pneumothorax in the presence of alternating pneumothorax, and 3) persistent air leak with incomplete lung re-expansion in the presence of spontaneous pneumothorax treated with pleural drainage for more than 10 days. No deaths were observed in the present series. Post-operative complications were minimal and all reversible, including two cases of pleural effusion, one case of hemothorax, and one case of Horner's syndrome. Eighty cases were followed up from 7 to 91 months. No recurrences occurred during the follow-up period. Clinical, radiological and functional results appear satisfactory. Pleural abrasion seems to represent a valid surgical option in the treatment of recurrent or persistent spontaneous pneumothorax.     

Re-expansion pulmonary edema in a patient with total pneumothorax: a hazardous outcome

Re-expansion pulmonary edema (REPE) is a rare complication of treatment of spontaneous pneumothorax or large pleural effusions. As a complication of spontaneous pneumothorax treatment, only few cases are documented, and even fewer document the role of non-invasive continuous positive airway pressure mechanical ventilation for treatment of this rare entity. We present a case of 23-year-old man who presented with left-sided pneumothorax, developed unilateral REPE and was treated with non-invasive continuous positive airway pressure.     

Surgical indications and technique of persistent and recurrent spontaneous pneumothorax]

The thoracotomy is the most invasive and most effective method for treatment of spontaneous pneumothorax. This method is indicated not only for recurrent pneumothoraces but also if conservative treatment does not induce expansion of lung. The primary operation is indicated absolutely in only some cases (spontaneous hemopneumothorax, pneumothorax in pregnancy). Today it is possible to operate for relative indications: Surgery has a small rate of complications, mortality and relapse (below 1%). The operation removes the causes of pneumothorax and protect for relapse of the pneumothorax via pleurodesis with mechanical irritation of the pleural surface.     

Five cases of contralateral pneumothorax after lung resection

Contralateral pneumothorax is one of severe complications after lung resection. We present our experiences with surgical treatment of 5 cases [case 4 is under the percutaneous cardiopulmonary support (PCPS) assistance] of contralateral pneumothorax after lung resection. All cases were men and not able to stop smoking, the disease caused by lung resection was lung cancer 3 and tuberculosis 2. Operative procedure was lobectomy 4 and pneumonectomy 1. Tracheal intubation was done before radiological confirmation of pneumothorax in 4 cases. Immediately after diagnosis all patients underwent chest drainage. Because the contralateral pneumothorax after lung resection is severe complication, we thought that surgical treatment is necessary. Though the thoracoscopic surgery under the PCPS assistance is also possible, it seems that a small thoracotomy with adjusting ventilation by anesthetist are more favorable. Accurate diagnosis and treatment is the key for success of treatment. The patient who receives lung resection due to lung cancer often has emphysema, and the risk of contralateral pneumothorax after the operation should also be explained.     

Management of Spontaneous Pneumothorax

Recurrence is the most common complication of spontaneous pneumothorax. Open thoracotomy with resection or obliteration of blebs and parietal pleurectomy provides the best protection against recurrence. Twenty-seven consecutive patients underwent open thoracotomy for recurrent pneumothorax with no mortality and minimum morbidity and have remained free from recurrence. We believe that thoracotomy should be more widely used in the treatment of what is called spontaneous pneumothorax, since this treatment may remove the real cause of the disease.     

Long-term follow-up of planned treatment of spontaneous pneumothorax

Lichter, I. (1974).Thorax, 29, 32-37. Long-term follow-up of planned treatment of spontaneous pneumothorax. Ninety-six patients presenting with spontaneous pneumothorax have been followed for a period of five to 12 years after initial treatment. Treatment was designed to deal with the pneumothorax episode and management was planned to minimize the risk of recurrence. Patients were treated initially by intercostal tube drainage, and subsequent management depended upon the nature of the underlying disease and the behaviour of the pneumothorax.     

Surgical treatment for secondary pneumothorax in elderly patients

Surgical treatment for secondary pneumothorax in elderly patients is very difficult because of having a high perioperative risk related to the presence of underlying chronic lung disease. In this study, we performed a retrospective review of elderly (> or = 70 years old) 35 patients with secondary pneumothorax who underwent surgical treatment between 2000 and 2009. Of the 35 patients, 31 were men and 4 were women with an average age 77.9 years old. Seventeen patients of them had already received oxygen therapy. They were not only in chronic respiratory failure but also malnutrition. Hospital mortality rate was 14.3%. Three patients died within 30 postoperative days and 2 patients were with hospital death after operation. The 5-year survival rate in patients with secondary pneumothorax was 41.7%. Although secondary pneumothorax is one of benign pulmonary diseases, its prognosis in elderly patients is poor. In conclusion, prompt diagnosis and treatment of secondary pneumothorax in elderly patients are mandatory. They could improve the outcome of this disease.     

Diagnosis and treatment of nonspecific spontaneous pneumothorax

The authors analyze the treatment of 74 patients with non-specific spontaneous pneumothorax. Relapses were observed in 6.7% of cases. The authors have shown that a partial pneumothorax should be treated actively and conservatively. By this method in 61 of 74 patients (82,6%) the lungs were expanded. Operations were performed in 13 patients. The surgical treatment is indicated in complete pneumothorax complicated by stable collapse of the lung, continuous intrapleural hemorrhage and suppuration of the pleural cavity.     

Video-assisted thoracic surgical treatment of initial spontaneous pneumothorax in young patients

BACKGROUND: The treatment of primary spontaneous pneumothorax in young adults has been controversial. Conventional treatment consisting of chest tube thoracostomy may be associated with morbidity at the time of tube insertion, prolonged hospitalization, and interval operation in many patients. As spontaneous pneumothorax in young adults is usually associated with apical blebs, we hypothesized that video-assisted thoracic surgical (VATS) resection of the blebs at the time of the first pneumothorax may be an effective treatment associated with low morbidity and short hospital stays. METHODS: From July 1992 to February 2001, 156 young adults were treated for spontaneous pneumothorax. Within 12 hours of presentation to the emergency department patients underwent semielective VATS with bleb resection and pleuradesis. During follow-up patients were observed for recurrent pneumothorax. RESULTS: There were 69 men (44%) and 87 women (56%). The median age was 19 years old (range 14 to 38 years old). Patients were predominantly tall and thin. Patients were mildly symptomatic at the time of presentation. Apical blebs were seen in all patients and the presence of blebs was confirmed in the pathologic specimen. In 23 patients bleeding was associated with bleb rupture. There were no postoperative air leaks. The mean hospital stay was 2.4 +/- 0.5 days. Follow-up ranged from 2 to 96 months (median 62 months). There were no recurrences on the index side. CONCLUSIONS: VATS resection of apical blebs is associated with low morbidity and short hospitalization and provides an attractive alternative to the conventional treatment of initial tube thoracostomy and possible interval repeat thoracostomy or operation. VATS may be an effective first line treatment for spontaneous pneumothorax in young adults. Due to the pathophysiology of this disease, patients should be closely followed for the occurrence of pneumothorax on the contralateral side.     

Pneumothorax in the neonatal period

The incidence of pneumothorax in the neonatal period is reviewed. Most infants who developed a pneumothorax were undergoing intermittent positive pressure ventilation. The most common underlying pathology associated with pneumothorax was idiopathic respiratory distress syndrome. This was the only condition in which a pneumothorax occurred in spontaneously breathing patients. The development of a pneumothorax was not significantly related to gestational age, birth weight, high ventilator inflation pressure, maximum fractional inspired oxygen concentration or the method of delivery. Evidence is presented to suggest that the development of a pneumothorax is not primarily a complication of ventilation but is due to the more severe pulmonary pathology of infants who require ventilatory assistance. Whatever the mechanism, prompt diagnosis and treatment mean that this common complication does not necessarily increase mortality.