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.     

Spontaneous and recurrent pneumothorax. Surgical treatment. Apropos of 278 cases]

Over the past 19 years, 278 patients (238 men-40 women) have undergone 325 parietal pleurectomies: 311 transaxillary apical and 14 full pleurectomies. Mean age was 32 +/- 12 years. The overall male:female ratio was 6:1. Surgical treatment was performed for either recurrence of spontaneous pneumothorax or failure to respond adequately to management by tube drainage. Thirty-six patients underwent one stage bilateral apical pleurectomy. On the basis of our experience (idiopathic pneumothorax: 311; chronic obstructive lung disease: 12; histiocytosis X: 2), we advocate the use of transaxillary apical pleurectomy for the younger age group with recurrent idiopathic pneumothorax and a full pleurectomy in the older age group. Major complications occurred in 1.9% of cases (re-exploration for haemorrhage: 5 cases; for air leak: 1 case). The recurrence rate in this group of patients was 1% (3 in 278 patients: one of them has been reoperated).     

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.     

Video-assisted thoracoscopic surgery for primary spontaneous pneumothorax: clinicopathological correlation.

OBJECTIVE: To compare the identifiable pulmonary abnormalities during thoracoscopy with the histological findings in patients requiring surgical intervention for recurrent or persistent primary spontaneous pneumothorax (PSP) and correlate these with the postoperative events. METHODS: From January 1999 to December 2002, 94 consecutive patients underwent video-assisted thoracoscopic wedge excision and apical pleurectomy for PSP. Vanderschueren's classification was used for macroscopic staging and histological observation for microscopic features. Clinical data of these patients and the outcome of surgery were described. RESULTS: All patients were successfully treated using video-assisted thoracoscopic technique. Recurrent pneumothorax was the most frequent indication for surgery, occurring in 60 cases. The method of management was stapling of an identified bleb or apex of the upper lobe and apical pleurectomy. In 67 cases (71%), clear bullae were found in types III and IV. In 15 cases (16%), type II pleuropulmonary adhesions were identified and in 12 (13%) cases thoracoscopy failed to reveal any abnormality (type I). The actual site of air leakage could be located during thoracoscopy in 24 (26%) patients. Histologically, 74 patients had subpleural bullae/blebs formation and 20 had emphysema without bullae. Fifty-three patients had cellular infiltration and 82 had pleural fibrosis. In the microscopic examination, the actual site of air leakage could be located at the site of subpleural blebs or bullae in 15 patients and elsewhere at the lung surface in five other patients. Postoperative prolonged air leak occurred in 4 out of 12 patients in type I and in two of the remaining patients, p=0.001. Mean follow-up is 48 months (range, 30-60 months) for all patients. Pneumothorax recurred in three patients (3.1%). Two patients from type I (16.6%) and one patient from the other types (1.2%) had recurrence (p=0.01). CONCLUSIONS: Video-assisted thoracoscopic stapling of an identified bleb or apex of the upper lobe and apical pleurectomy represents the standard treatment for the majority of recurrent or persistent PSP. Most patients with surgically treated PSP have subpleural blebs or bullae or isolated emphysema. In type I cases, simple apical excision and apical pleurectomy are not sufficient and perhaps additional talc poudrage might be indicated.     

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.     

Results of video-assisted thoracoscopic surgery for pneumothorax

INTRODUCTION: Video-assisted thoracoscopic surgery has been used in the treatment of pneumothorax since 1990. There is still no general agreement regarding the procedure to obliterate the pleural space or regarding the indication for wedge resection if no blebs or bullae can be found. PATIENTS AND METHODS: Clinical records referring to 100 video- assisted thoracoscopic operations for pneumothorax, performed in Berlin-Buch between 1998 and 2001, were retrospectively evaluated with regard to the rate of recurrences and postoperative complications in connection with the operative procedure. There were 70 male and 28 female patients aged from 16 to 78 years. The mean age was 34 years. The statistical significance was evaluated by the McNemar-test. RESULTS: 74 patients showed a regular postoperative course. Severe postoperative complications occurred in 9 patients: re-operation via thoracotomy n=5 (postoperative bleeding n=2, recurrence n=2, persistent air-leak n =1); re-thoracoscopy n=3 (postoperative bleeding n=2, recurrence n=1), pleural empyema n=2. The complication rate was significantly higher (p < 0.001) in patients with underlying pulmonary diseases (secondary spontaneous pneumothorax) or thoracic surgery in their history. Depending on the intraoperative situation, the cause of pneumothorax and the patient's general condition the pleural space was obliterated by the following procedures: apical parietal pleurectomy (n=85), electro-pleurodesis alone (n= 7), electro-pleurodesis and pleural abrasion (n=3), talcum poudrage (n=2). The rate of major complications was lower (p < 0.001) when pleurectomy was performed 8.2 % (7/85) compared to those operations performed without pleurectomy 13.3 % (2/15). The rate of re-operations for recurrences/persistent air leaks or empyemas following persistent air leaks was significantly lower (p < 0.001) when wedge resection 3.75 % (3/80) had been performed compared with operations without wedge resection 10 % (2/20). DISCUSSION: Apical parietal pleurectomy and wedge resection of blebs or bullae are effective methods to prevent recurrences. Considering the specific complications of parietal pleurectomy alternative methods to obliterate the pleural space should be used depending on the intraoperative situation. Among other factors underlying pulmonary diseases or thoracic surgery in the patient's history strongly influence the postoperative outcome independently of the operative procedure.     

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.     

Does a thoracic epidural confer any additional benefit following video-assisted thoracoscopic pleurectomy for primary spontaneous pneumothorax?

OBJECTIVE: Video-assisted thoracoscopic (VATS) bullectomy and apical pleurectomy has become the preferred procedure for recurrent or complicated primary spontaneous pneumothorax (SPN). Although thoracic epidural analgesia is the gold standard after open thoracic surgical procedures, its use in the management of minimally invasive procedures in this young population has not been extensively studied. METHODS: From 1997 to 2003, a single surgeon performed 118 consecutive VATS pleurectomies for primary SPN. The perioperative course, analgesic requirements, hospital stay and long-term complications were compared for 22 (18%) patients in whom a patient-controlled thoracic epidural was used for analgesia and 96 (82%) patients who did not receive an epidural (parenteral opioids). A four-point verbal pain score (0-3) was recorded hourly in every patient at rest and on coughing following surgery. RESULTS: One patient required additional surgery for evacuation of haemothorax. There were no mortalities or other major complications in the series. Overall median hospital stay was 3 (range 1-10) days, the incidence of long-term pain at 3 months was 6%, and the long-term recurrence rate was 3%. Despite parenteral opioids being discontinued significantly earlier than epidurals, pain scores were similar in both groups. There were no significant differences in the duration of air-leaks, length of drainage, hospital stay, long-term pain and long-term paraesthesias between the two groups. CONCLUSIONS: Thoracic epidural analgesia does not contribute significantly to minimize neither perioperative nor long-term pain after VATS pleurectomy for primary SPN. The additional resource requirement in these patients is not justified.     

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.     

Pattern of recurrence and survival of c-Ia NSCLC diagnosed by transpleural methods

AIM: The aim of this study was to evaluate if transpleural diagnostic methods as percutaneous fine-needle aspiration biopsy (FNAB) or tumour wedge resection by video-assisted thoracoscopic surgery (VATS) impact on local recurrence and long term survival of patients affected by non-small cell lung cancer (NSCLC). METHODS: Records concerning 179 patients with peripheral c-Ia NSCLC who underwent complete resection from 1994 to 2000 have been reviewed. Patients were randomized into two groups according to the diagnostic method employed, as follows: in group I (N.=63) diagnosis was obtained by bronchoscopy; in group II (N.=116) diagnosis was obtained by FNAB (N.=59) or tumour wedge resection by VATS (N.=57) after a negative bronchoscopy. Survival curves were compared using log-rank test. Distribution of frequencies was analyzed with Chi-square and Fisher's exact test. RESULTS: The two groups of patients did not significantly differ in terms of age, gender, forced expiratory volume in 1 second, comorbidities, histological type and tumour size; pathologic stage IIb was more frequent in group I. At a median follow-up of 48 months, (range 2-108 months), local recurrence was found in 9.5% (N.=6) of the patients in group I and in 12.5% (N.=15) of patients in group II (P=NS); distant metastasis were found in 28.6% (N.=18) of patients in group I and in 13.8% (N.=16) in group II (P=0.03). Patients in group II had a statistically better five-year survival rate than patients in group I (70% and 55% respectively P=0.016). CONCLUSION: FNAB and tumour wedge resection by VATS represent valuable diagnostic methods for lung cancers, since they do not seem to increase the risk of local recurrence. On the other hand, tumours diagnosed by bronchoscopy have a worse prognosis, that may be related to their higher metastatic potential rather than to diagnostic procedure itself.     

Video-assisted thoracic surgery for metachronous lung cancer

Of 1,391 patients who underwent operation for primary lung cancer between 2000 and 2009, 50 patients (3.6%) had a past history of pulmonary resection for lung cancer. Three patients underwent completion pneumonectomy by thoracotomy and in the other 47 patients video-assisted thoracic surgery (VATS) was performed. We considered 42 cases (3 of completion pneumonectomy and 39 of VATS) to be metachronous lung cancer and 8 cases of VATS to be recurrence by detailed histologic assessment. We examined 39 cases of metachronous lung cancer resected by VATS. The patients were aged 68 +/- 8 years and 4 patients were aged 80-years or more. The surgical procedures performed were lobectomy in 4 patients, segmentectomy in 3, and wedge resection in 40. The operation time was 121 +/- 66 minutes and the blood loss was 67 +/- 140 ml. There were no major complications. We registered 6 deaths during follow-up; 3 were due to disease progression and 3 were due to other causes. The survival rate of the 42 patients including 3 patients who underwent completion pneumonectomy was 74.9% at 5 years. Early detection of metachronous lung cancer and surgical resection offers a favorable prognosis.     

Diagnostic and treatment strategy for patients with the first episode of primary spontaneous pneumothorax

A retrospective analysis of 198 patients (164 men and 28 women) with the first episode of primary spontaneous pneumothorax (PSP) was made. All the patients underwent diagnostic thoracoscopy (DT) under local anesthesia before insertion of a chest tube. For 115 patients the chest tube thoracoscopy was the only treatment procedure (group I) and 77 patients underwent video-assisted thoracoscopic (VATS) wedge (atypical) resection and pleurectomy (group II). The patients were followed-up from 13 through 77 months. In group I there were 19 recurrences (16.5%), and only two recurrences in group II. In patients of group II having no pathological changes there were no recurrences while in group I there were two (3.3%). The recurrence rate in patients with pathological changes (II, III and IV stages of Vanderschuren classification) was 3% after VATS and as high as 31.5% after the chest tube treatment. The diagnostic thoracoscopy should be performed in all patients with the first episode of PSP for the assessment of the lung and pleura condition. The presence of any pathological changes points to a high risk of recurrences and should be considered as an indication for antirelapse measures (VATS). Surgery is not necessary when no morphological alterations are revealed at DT.     

Surgical experience in the management of spontaneous pneumothorax, 1972-82

In the past 11 years 233 patients have undergone 241 parietal pleurectomies for either recurrence of their spontaneous pneumothorax or failure to respond adequately to management by tube drainage. Major complications occurred in 3.7% of cases, with transaxillary apical pleurectomy engendering significantly fewer complications than full pleurectomy through a posterolateral thoracotomy. The significantly larger number of minor complications, however, in patients undergoing full pleurectomy was largely due to the larger number of patients with chronic obstructive lung disease in this group. On the basis of our experience we advocate the use of transaxillary apical pleurectomy for the younger age group with recurrent pneumothoraces and a full pleurectomy in the older age group, who frequently present because of failure to respond satisfactorily to tube drainage during their initial pneumothorax and often have lung disease secondary to chronic obstructive lung disease which is not confined to the apex of the upper lobe.     

Quality of life evolution after surgery for primary or secondary spontaneous pneumothorax: a prospective study comparing different surgical techniques

The objective of the present study is to evaluate quality of life (QoL) evolution after video-assisted thoracic surgery (VATS) and anterolateral thoracotomy (AT) for primary and secondary spontaneous pneumothorax, which has not been studied prospectively until now. From January 2003 to December 2004, QoL was prospectively recorded in 20 consecutive patients, using the European Organisation for Research and Treatment of Cancer (EORTC) QoL Questionnaire-C30 and the lung specific module LC-13. Questionnaires were administered before surgery and 1, 3, 6 and 12 months postoperatively (MPO) with response rates of 100%, 85%, 80%, 65% and 60%, respectively. In this prospective, non-randomized study, all patients had wedge resection and apical pleurectomy, 45% by video-assisted thoracic surgery (VATS), and 55% by anterolateral thoracotomy (AT). In general, patients QoL subscales improved after surgery. After VATS, pain (3 MPO P=0.012), dyspnoea (1 MPO P=0.030) and thoracic pain (1 MPO P=0.038) decreased significantly. After AT, a significant increase was seen in general QoL (1 MPO P=0.036, 3 MPO P=0.034, 12 MPO P=0.025), physical (6 MPO P=0.025) and emotional functioning (12 MPO P=0.017). Dyspnoea (12 MPO P=0.042) and coughing (6 MPO P=0.046) decreased after AT. After surgery, AT and VATS are comparable in QoL evolution with the exception of a significant difference at 1 MPO in physical, role and cognitive functioning (P=0.002, P=0.002 and P=0.0018, respectively) and dyspnoea (P=0.041) in favour of VATS. Comparing VATS and AT in QoL evolution, significant differences are seen in thoracic pain evolution in favour of VATS (6 MPO P=0.037). After surgery, AT and VATS are comparable in QoL subscales with exception of a significant difference at 1 MPO in favour of VATS. Dyspnoea and coughing improved after surgery.     

Video-assisted thoracic surgery (VATS) lobectomy for typical bronchopulmonary carcinoid tumors

Background: Indications for the use of video-assisted thoracic surgery (VATS) lobectomy are a controversial matter. This study aims to provide a retrospective evaluation of VATS lobectomy in typical bronchopulmonary carcinoids. Methods: Patient selection criteria for VATS lobectomy were as follows: (a) typical carcinoids with clear diagnosis; (b) centrally located lung tumors not amenable to bronchial resection with bronchoplastic procedures, or tumors located in peripheral lung tissues; (c) no hilar or mediastinal lymph node enlargement; and (d) normal respiratory function. Between January 1995 and December 1999, 12 patients (eight men and four women with a mean age of 57 years) were treated, seven with a peripheral and five with a centrally located tumor. Preoperative examination included chest roentgenograms, computed tomography (CT) of the chest, bronchoscopy, and spirometry; diagnosis was established by direct bronchoscopy in five cases, transbronchial biopsy in two cases, transthoracic biopsy in two cases, and videothorascopic wedge resection in three cases. Eleven VATS lobectomies and one VATS bilobectomy were performed. All patients underwent hilar lymphadenectomy and mediastinal sampling. Results: There were no intraoperative complications. The only postoperative complication, hematothorax (8.3%), required VATS reoperation. Mean postoperative hospital stay was 5.33 days. Pathological examination of the resected specimens confirmed that the procedure was radical in all 12 patients and revealed eight T1N0 and four T2N0. At a mean follow-up of 30 months, no signs of recurrence were recorded. Conclusion: VATS lobectomy in the treatment of selected typical carcinoids, both central and peripheral, seems to yield favorable results and is therefore preferable to thoracotomy since it is less invasive. Received: 21 January 2000/Accepted: 11 May 2000/Online publication: 5 October 2000     

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.     

肺段切除与肺楔形切除对肺小气道功能影响的对比研究

目的比较分析胸腔镜解剖性肺段切除及肺楔形切除术对肺小气道功能的影响。 方法收集2021年1~6月期间,在民航总医院行胸腔镜肺段切除及肺楔形切除124例患者资料,其中行解剖性肺段切除64例、肺楔形切除60例。通过比较两组患者术前、术后1周,以及术后1、3、6个月的MEF25%、MEF50%、MEF75%/25%变化,明确肺段切除与肺楔形切除对肺小气道功能的影响。 结果MEF50%、MEF75%/25%、MEF25%两组指标术后1周均降低,两者之间差异无统计学意义;术后1个月较术后1周升高,且肺楔形切除组较肺段切除组结果升高;术后3个月两组指标均较前升高,且肺楔形切除组仍较肺段切除组结果高;MEF50%、MEF75%/25%术后6个月恢复至术前水平,MEF25%肺楔形切除组恢复至术前水平,较肺段切除组指标高,肺段切除组尚未恢复至术前水平。 结论小气道肺功能指标更能反映出机体肺功能情况;对于<1 cm且实性成分<5 mm的肺小结节,肺楔形切除术后肺功能指标比肺段切除恢复较快;提示切除肺部组织越小,保留的肺功能越多,越具有长期的功能优势。     

Spontaneous pneumothorax rates following video-assisted thoracoscopic talc pleurodesis with or without resection of macroscopic bullous disease

Background

Recurrent primary spontaneous pneumothorax (PSP) is routinely treated by video-assisted thoracoscopic (VATS) talc pleurodesis (with or without localized resection of macroscopic bullous disease). There is a paucity of published data regarding durability of the procedure and the rate of recurrent pneumothorax after such surgery, and this has significant implications from a prognostic and employment limitation perspective.

Methods

Patients who underwent a VATS talc pleurodesis (with or without localized resection of macroscopic bullous disease) for the treatment of their second or subsequent PSP or a PSP were followed for recurrent ipsilateral pneumothorax and new contralateral PSP. Follow up was by way of telephone interview and medical record verification out to 48 months.

Results

New contralateral pneumothorax occurred in 7 patients (11.1%) in the talc pleurodesis plus wedge resection group and 2 (1.8%) in the talc pleurodesis only group. There was one case of recurrent ipsilateral pneumothorax in a patient who had no inflammatory response to talc insufflation.

Conclusion

Video-assisted thoracoscopic (VATS) talc pleurodesis (and lung resection for macroscopic bullous disease) is a durable treatment for recurrent PSP. Patients with macroscopic disease have a significant risk of subsequent contralateral PSP.     

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.     

VATS is an adequate oncological operation for stage I non-small cell lung cancer

Objectives: This study was designed to determine the long-term prognosis of video-assisted thoracic surgery (VATS) vs. open lung resections for patients with pathological stage I non-small cell lung cancer (NSCLC). Materials and methods: The medical records of all patients who underwent lung resection for a pathological stage I NSCLC were reviewed for the period from 1990 to 1999, by screening of a database into which data were entered prospectively. There were 511 patients (430 males and 81 females) whose age averaged 63±10 years who underwent 515 lung resections. Our VATS experience began in 1993 with selected stage I patients, and since that date an average of one patient on four was managed with VATS. Lung resections consisted of 25 wedge resections or segmentectomies (seven VATS), 390 lobectomies (92 VATS), 19 bilobectomies (one VATS) and 81 pneumonectomies (ten VATS). Lymph node dissection was performed in all cases. Results: There were significantly more females (P=0.01) and adenocarcinoma (P=0.02) in the VATS group (n=110) when compared to the open group (n=405). Tumour size averaged 4±2 cm in the open group and 3±2 cm in the VATS group (P=0.04). The distribution of T1/T2 tumours was 97/308 and 50/60, respectively (P=0.0001). At follow-up, cancer recurrence could be documented in 117 patients, with no difference of incidence between the two groups (22.5 vs. 24.5%; P=0.64). Estimated Kaplan–Meier 5-year survival rates, including the operative mortality as well as any cancer-related and unrelated death, were 62.8% (confidence interval (CI): 56.8–68.7%) vs. 62.9% (CI: 51.4–74.4%), respectively (P=0.60). The advent of VATS did not influence the patients' survival: 5-year survival rate was 63.9% (CI: 55.3–72.5%) for the period from 1990 to 1992, and 58.8% (CI: 51.7–65.9%) for the period from 1993 to 1999 (P=0.65). Subgroups survival analysis according to the T status did not show any statistically significant difference between the two groups. Conclusions: VATS lung resection with lymph node dissection achieved a 5-year survival similar to that achieved by the conventional approach. VATS is a valuable option for the management of selected patients with an early-stage NSCLC.