Video-assisted thoracic surgery as a primary therapy for primary spontaneous pneumothorax

Background: Because blebs are confirmed in most of the patients undergoing thoracotomy, identification of blebs by high-resolution computed tomography (HRCT) can be proposed as a surgical indication in primary spontaneous pneumothorax (PSP). If an apical bleb is identified, we treat the patient by video-assisted thoracic surgery (VATS). Methods: From May 1995 to September 1997, 61 patients (21.9 ± 4.6 years) were seen for initial episodes of PSP. Only seven showed bullae on simple chest radiography. However, by HRCT, 48 had sizable blebs (>5 mm), and 45 were treated surgically by VATS. Results: The mean duration of chest tube use after surgery was 3.2 ± 1.9 days, and the mean hospital stay was 4.5 ± 1.9 days. Only one recurrence developed 5 weeks after VATS. Conclusions: Our protocol is effective in controlling an initial episode of PSP. It shortens the observation time before definitive surgical treatment, shortens the hospital stay, and decreases the likelihood of recurrence. Received: 25 June 1997/Accepted 18 February 1998     

Less invasive needle thoracoscopic laser ablation of small bullae for primary spontaneous pneumothorax.

OBJECTIVE: The purpose of this study was to establish a new surgical technique of thoracoscopic laser ablation for the patients of primary spontaneous pneumothorax (PSP) with small bullae, by using endoscopic equipment with a 2-mm diameter. METHOD: According to the size of a bulla identified by high-resolution computed tomography (HRCT), we have a protocol to determine an indication; the conventional video-assisted thoracic surgery (VATS) procedure by both stapler bullectomy and laser ablation to visceral pleura surrounding the bulla (bullae size: greater than 2 cm), or a new VATS procedure using needle shaped thoracoscopy and endoscopic equipment with a 2-mm diameter (needle VATS) by laser bulla ablation alone (bullae size: less than 2 cm). RESULTS: The conventional VATS was performed in 54 patients and needle VATS in 60 patients. In the needle VATS group, operation time was shorter than that of the VATS group (39+/-17 min vs. 56+/-22 min). Use of non-steroidal anti-inflammatory drugs for postoperative wound pain could be reduced in the needle VATS group (3% vs. 56%). There were no complications in the needle VATS group, but three complications (5.6%) in the VATS group, including prolonged air leakage (>4 days) in two and refractory intercostal pain in one. The rate of recurrence after the operation was similar in both groups (3.7% vs. 3.3%). The needle VATS allowed wound healing without a scar and reduced the patient's cosmetic problems. CONCLUSION: The needle VATS procedure for patients with a bulla size less than 2-cm diameter was as useful as the conventional VATS procedure.     

Recurrence of primary spontaneous pneumothorax

BACKGROUND: Primary spontaneous pneumothorax (PSP) is a common clinical problem and its incidence is thought to be increasing. The risk of recurrence is high and various studies quote rates of 20-60%. Factors which may or may not predispose to recurrence have not yet been established. METHODS: In a study period of four years 291 cases with a diagnosis of pneumothorax were reviewed; 153 patients with PSP were included in the study. Their risk of recurrence was analysed with particular reference to the following variables: age, sex, height and body mass index (BMI) of the patient, the initial size of pneumothorax, the smoking status of the patient, and the primary form of treatment employed. Univariate analysis was carried out by chi 2 testing and multivariate analysis was calculated by a logistic regression model. RESULTS: A retrospective study of 275 episodes of PSP in 153 patients over a four year period confirmed a high incidence of recurrence (54.2%). PSP was twice as common in men as in women, though women were significantly more likely to develop a recurrence (chi 2 = 7.58, df = 1, p < 0.01). Male height was the second most important factor, and smoking cessation the only other variable which significantly influenced the risk of recurrence. CONCLUSIONS: Analysis of several potential risk factors revealed that recurrence was not related to the BMI of the patient, the initial treatment of the pneumothorax, nor to its size. Recurrence was more common in taller men and in women. Smoking cessation appeared to reduce the risk of recurrence. These findings are discussed in the context of the possible aetiology of spontaneous pneumothorax, recurrences, and the management thereof.


     

Single-incision thoracoscopic surgery for primary spontaneous pneumothorax

Objective  

Single-incision laparoscopic surgery had been proven effective for appendectomy, cholecystectomy, and inguinal hernia repair. However, single-incision thoracoscopic surgery (SITS) in primary spontaneous pneumothorax (PSP) has not been reported.     

Management of surgical approach for intractable secondary spontaneous pneumothorax

Secondary spontaneous pneumothorax (SSP) such as lymphangioleiomyomatosis (LAM), bronchiolitis obliterans (BO) is intractable or repeated the recurrence of pneumothorax. The most effective chemical pleurodesis for intractable pneumothorax is talc poudrage and so on that is associated with a reduction in the rate of pneumothorax recurrence. However, severe and broad pleural adhesion due to the pleural interventional procedures sometimes cause serious bleeding when the patients undergo lung transplantation. We must be considered for new approaches to these intractable secondary pneumothoraces which replaced traditional conservative and surgical approaches. We had proposed new 2 approaches of total pleural covering (TPC) and awake surgical intervention (ASI) for intractable pneumothorax. We applied the TPC modified with coverage of air leak points with polyglycolic acid (PGA) sheet to 5 patients with intractable bilateral pneumothorax to reduce the risk of excessive bleeding by chemical pleurodesis in lung transplantation. The bilateral pneumothorax was well controlled, and no recurrence has been observed. TPC is reliable procedure for management intractable bilateral SSP. For 12 high-risk patients with other underling pulmonary diseases on general poor conditions, a surgical intervention was performed in awake condition. The air leaks were stopped in 11 cases except for 1 case. The recurrence of pneumothorax after surgery was 2 cases. ASI for intractable secondary pneumothorax can be applicable to selected patients with deteriorated general condition.     

Thoracoscopic management of primary spontaneous pneumothorax

Primary spontaneous pneumothorax is defined as that which appears in patients without history of previous pathology that could explain the event. Management includes pleural drainage with or without pleurodesis and surgical resection of affected lung tissue with pleurodesis. Thoracoscopic approach has proved to be useful with low morbidity and mortality as well as low recurrence rate. This paper describes the experience with thoracoscopic management of primary spontaneous pneumothorax with pulmonary wedge resection of affected tissue, parietal pleurectomy, and pleural abrasion of remaining parietal and diaphragmatic pleura. Fifty-five patients have been submitted to this approach (24 female, 31 male). Fifty-three patients had past history of at least one previous pneumothorax (second event, n=41; third event, n=9; fourth event or more, n=3). Computed tomography was abnormal in 19 patients. Operative time was 57 minutes (+/-17). There were no transoperative complications. Macroscopic findings were presence of small type I bullae in the lung apex in 48; three more had apical pleural thickening. None of the patients presented postoperative air leak. Chest tubes were removed after 24-48 hours on average. Adequate pain control was achieved in 51 patients; 4 patients presented mild chronic intercostal pain for 3-5 months. Median follow-up was 48 months (range 6-72); no recurrence has been observed. Primary spontaneous pneumothorax can be managed thoracoscopically; management should include wedge resection of affected lung, apical pleurectomy, and pleural abrasion of remaining parietal and diaphragmatic pleura.     

低成本两孔胸腔镜手术治疗原发性气胸

目的探讨一种简单、微创、经济的腔镜方法治疗自发性气胸。 方法收集2011年10月至2016年2月胸腔镜手术治疗自发性气胸84例,其中两孔胸腔镜肺大疱结扎54例(试验组),三孔胸腔镜肺大疱切割缝合器楔形切除30例(对照组)。试验组,根据胸壁不同厚度把肺大疱拉近操作孔或拉至操作孔或拉出操作孔用手直接结扎/缝扎后做机械摩擦的胸膜固定术;对照组按常规进行,用切割缝合器行肺楔形切后做机械摩擦的胸膜固定术。 结果两组患者的临床效果差异无统计学意义(P>0.05),试验组的住院费用低于对照组[(16 747.30±2 586.41) 元 vs (21 088.54±6 005.68)元,P<0.05]。 结论两孔胸腔镜下肺大疱用手缝扎/结扎技术治疗自发性气胸简单、微创、经济。     

Thoracoscopic total parietal pleurectomy for primary spontaneous pneumothorax

Although the management of spontaneous pneumothorax through a thoracotomy traditionally included apical pleurectomy, thoracoscopic treatment of this problem does not generally include pleurectomy. Thoracoscopy in fact allows excellent exposure to perform total parietal pleurectomy, and we hypothesize that including total pleurectomy will reduce recurrences. We describe here the technique of thoracoscopic total parietal pleurectomy and the early outcomes afterward.     

Pleural tenting in complicated primary spontaneous pneumothorax

AIM: To assess the efficacy of pleural tenting in patients with complicated primary spontaneous pneumothorax (PSP). METHODS: From 1988 through 2001, 43 patients underwent operations. Mean age was 30.4 years; the male/female ratio was 9.7. Twenty-one (48.8%) underwent pleural tenting in addition to bulla excision (experimental group, EG). Twenty-two (51.2%) underwent bulla excision plus pleural abrasion (11 patients), apical partial pleurectomy (9 patients) and complete apical pleurectomy (2 patients) (control group, CG). The most frequent symptom was chest pain (37.2%). Surgical indications were recurrence in 21 (48.8%), prolonged air leak in 12 (27.9%), failure of expansion without air leak in 6 (13.9%), high risk occupancy in 2 (4.6%) and empyema due to air leak in 2 (4.6%). RESULTS: Air leak time was decreased by tenting (1.9 days vs 3.7 days) as well as time of drainage (4.8 vs 6.9) and hospital stay (5.8 vs 7.9). Morbidity was 9.5% in EG and 9.1% in CG. Causes of morbidity were postoperative hematoma, prolonged air leak, expansion failure and blunt posterior sinus one of each. Re-operation needed for postoperative hematoma in CG. Mean follow-up was 5.1 years and 1 (4.5%) recurrence observed in CG. CONCLUSION: Tenting of the dependent lung from the apical pleura after bullectomy via axillary thoracotomy lessens air leak time without recurrence and low morbidity.     

Results of thoracoscopic pleural abrasion for primary spontaneous pneumothorax

Background: Several video-assisted techniques have been used to treat primary spontaneous pneumothorax (PSP). The aim of this study was to evaluate the results of thoracoscopic pleural abrasion for PSP. Methods: From 1991 to 2003, 185 consecutive patients, 143 male and 42 female, aged 15 to 60 years (average 31.6) underwent thoracoscopic pleural abrasion for PSP. The indications for surgery were as follows: a first episode with persistent air leak in 33 patients (17.9%), a recurrent ipsilateral pneumothorax in 122 patients (65.9%), a previous contralateral pneumothorax in 23 patients (12.4%), and recurrence after surgical treatment in seven patients (3.8%). Bullae were resected in 163 patients (88.1%). Mechanical pleural abrasion was performed in all cases. Results: There were no deaths. Intraoperative hemorrhage occurred in three patients. It was controlled via thoracotomy in one patient and via thoracoscopy in two patients. The postoperative complication rate was 8.1% (15/185). Complications included prolonged air leak in eight patients (4.3%), pleural effusion in two (1.1%), extrapleural hematoma in one (0.5%), chest wall infection in one (0.5%), atelectasis in one (0.5%), and hemorrhage in two (1.1%). Postoperative hospital stay ranged between 2 and 17 days (mean, 5). Mean duration of drainage was 3.8 days (range; 1–16). Postoperatively, 111 patients were contacted, with a mean follow-up of 36.5 months. Four of them had a recurrence (3.6%) that did not require reoperation. Conclusion: Thoracoscopic pleural abrasion associated with bullae resection is a safe and efficient treatment for PSP. Results remain stable in the long term.     

Modified needlescopic video-assisted thoracic surgery for primary spontaneous pneumothorax

Background The objective of this study was to evaluate the feasibility and safety of modified needlescopic video-assisted thoracic surgery (VATS) for treating primary spontaneous pneumothorax. The efficacy between apical pleurectomy and pleural abrasion through this technique was also compared. Methods Between 2001 and 2003, 65 patients with primary spontaneous pneumothorax underwent modified needlescopic VATS procedures. The blebs were resected with endoscopic linear staplers. Pleurodesis was achieved by apical pleurectomy before September 2002 (n = 30) and by pleural abrasion for the remainder of the study period (n = 35). Results Mean operation time was 103 min in the pleurectomy group and 78 min in the abrasion group (p = 0.001). Complications developed in four patients (6.2%): prolonged air leaks in three patients and wound infection in one patient. The mean postoperative hospital stay was 3.8 ± 1.8 days. The two groups had comparable doses of requested analgesics, complication rates, postoperative chest tube and hospital stays, and postoperative pulmonary function test. Ipsilateral recurrence did not occur in any of the pleurectomy group patients after a mean follow-up of 31 months, but it occurred in three patients (8.6%) in the abrasion group after a mean follow-up of 19 months. Conclusions Modified needlescopic VATS provides a feasible and safe procedure for treating primary spontaneous pneumothorax. In terms of efficacy, apical pleurectomy is more effective in preventing ipsilateral recurrence than pleural abrasion.     

Recurrence rate after thoracoscopic surgery for primary spontaneous pneumothorax

Objectives: There is an on-going discussion regarding the recurrence rate after surgery for primary spontaneous pneumothorax by video assisted thoracic surgery (VATS) or by thoracotomy access. This study aimed to describe the recurrence rate, and to identify a possible learning curve, following surgery for primary spontaneous pneumothorax by VATS. Design: All patients who underwent surgery for primary spontaneous pneumothorax by VATS at Karolinska University Hospital 2004–2013 were reviewed. Preoperative and operative characteristics were obtained from medical records. Patients were followed-up through telephone interviews or questionnaires and by review of medical records. The primary outcome of interest was time to recurrence of pneumothorax requiring intervention. Outcomes were compared between patients operated during 2004-June 2010 and July 2010–2013. Results: 219 patients who underwent 234 consecutive procedures were included. The mean follow-up times were 6.3 and 2.9 years in the early and late period, respectively. The postoperative recurrence rate in the early period was 16% (11%–25%), 18% (12%–27%), and 18% (12%–27%), at 1, 3 and 5 years, compared to 1.7% (0.4%–6.8%), 7.6% (3.7%–15%), and 9.8% (4.8%–19%) at 1, 3 and 5 years, in the late period (p?=?0.016). Conclusions: We found that the recurrence rate after thoracoscopic surgery for primary spontaneous pneumothorax decreased significantly during the study period. Our results strongly suggest that thoracoscopic surgery for pneumothorax involve a substantial learning curve.     

微创快速康复外科技术在治疗原发性自发性气胸中的应用进展

原发性自发性气胸(PSP)是一种比较常见的胸部疾病,绝大部分患者合并肺大疱形成,病情严重,其治疗方法多样,包括保守治疗或开胸手术、电视胸腔镜手术(VATS)等治疗,各有优缺点。采用不同的流程方法治疗,治疗的效果亦不相同。文章就近年来国内外在PSP的诊断、快速康复外科(FTS)治疗、临床应用方面做一简要综述。     

Video-assisted thoracic surgery for recurrent primary spontaneous pneumothorax in reoperated chests

Purpose  

There are few reports on video-assisted thoracic surgery (VATS) for recurrent primary spontaneous pneumothorax (PSP) in reoperated chests. We report our experience of performing redo VATS for recurrent PSP in reoperated chests.     

Unusual pathogenesis of spontaneous pneumothorax secondary to Wegener's granulomatosis

Spontaneous pneumothorax represents a rare and potentially severe complication of Wegener's granulomatosis. A 31-year-old man with Wegener's granulomatosis on immunosuppressive therapy was admitted for a right massive spontaneous pneumothorax. After chest drainage he presented with a prolonged air leak that required a surgical treatment. Histologic findings did not reveal any necrotizing granulomatous vasculitis, but only subpleural fibrous tissue. We hypothesize that pneumothorax could be related to the subpleural fibrous retraction induced by immunosuppressive therapy.     

Management of primary spontaneous pneumothorax: a review

Primary spontaneous pneumothorax is a common problem faced by doctors in medical practice. It is a significant global health problem affecting adolescent and young adults. This article will review the etiopathology, diagnosis and current management guidelines. It aims to improve clinical practice and compliance to the complexities of procedures involved in management.