Diagnosis of Birt-Hogg-Dube syndrome in a patient with spontaneous pneumothorax

Birt-Hogg-Dube syndrome refers to a dermatologic syndrome, consisting of small papular skins lesion distributed on the scalp, forehead, face and neck, which is autosomal dominantly inherited. Subsequently patients may develop concomitant renal and thoracic pathology. We report the case of a patient with Birt-Hogg-Dube syndrome diagnosed after spontaneous pneumothorax.     

Needlescopic versus conventional video-assisted thoracic surgery for primary spontaneous pneumothorax: a comparative study

BACKGROUND: Management of primary spontaneous pneumothorax by needlescopic video-assisted thoracic surgery (VATS) has rarely been attempted and no comparison study with conventional VATS is available. In this study, we compared the clinical outcomes of needlescopic VATS with conventional VATS in treating primary spontaneous pneumothorax. The technique and our experience with needlescopic VATS are reported. METHODS: Between April 2001 and April 2002, a total of 63 patients with recurrent, persistent, or contralateral primary spontaneous pneumothorax were recruited for this study. Operative procedures included needlescopic VATS in 28 patients and conventional VATS in 35 patients. We used a modified operative technique to improve the poor and narrower vision of the needle-videothoracoscope. RESULTS: There was no mortality or major complications in either of the two groups. Needlescopic and conventional VATS groups had comparable operation times, postoperative pain, requested doses of meperidine hydrochloride, durations of postoperative chest drainage, and length of hospital stay. After a mean follow-up of 8 months, the needlescopic VATS group had less residual neuralgia (p = 0.021) and better wound satisfaction (p = 0.043) than the conventional VATS group. Ipsilateral recurrence of pneumothorax occurred in 1 patient (3.6%) in the needlescopic VATS group but not in any patients in the conventional VATS group. CONCLUSIONS: Our experience showed that needlescopic VATS is technically feasible and can be a satisfactory alternative to conventional VATS in treating primary spontaneous pneumothorax. Limited vision of needlescopic VATS can be improved by the modified technique we used. However, conversion to conventional VATS or minithoracotomy is suggested in selected patients to prevent early recurrence.     

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.     

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.     

Axillary thoracotomy versus videothoracoscopy for the treatment of primary spontaneous pneumothorax

Background

A prospective, randomized study was carried out on patients with primary spontaneous pneumothorax, with the aim of determining if video-assisted thoracoscopy is superior to axillary thoracotomy in the surgical treatment of this condition.

Methods

Patients were randomly assigned to two groups; video-assisted thoracoscopy (group A; n = 46) and axillary thoracotomy (group B; n = 44). All fit the established criteria for surgical indication (relapse or persistent air leakage after pleural drainage). In all cases the treatment consisted of apical segmentectomy of the blebs or dystrophic complex and pleural mechanical abrasion. The study evaluated the following factors: postoperative blood loss, respiratory function (maximum inspiratory and expiratory pressures, forced expiratory volume in the first second and forced vital capacity), postoperative pain (analog visual scale), supplementary doses of analgesics, postoperative complications, hospital stay, and resumption of normal activity. Relapses were evaluated for the minimum period of time of two years.

Results

No significant differences were found in any of the factors studied in either group.

Conclusions

Video-assisted thoracoscopy and axillary thoracotomy offer similar results in the surgical treatment of primary spontaneous pneumothorax. The rate of complication is low and the level of pain is acceptable without long-term sequelae.     

Videothoracoscopic bleb excision and pleural abrasion for the treatment of primary spontaneous pneumothorax: long-term results

BACKGROUND: The goal of this study was to evaluate the long-term efficiency of videothoracoscopic bleb excision and pleural abrasion for the treatment of primary spontaneous pneumothorax. METHODS: From July 1991 to December 1997, 182 patients with primary spontaneous pneumothorax were treated by a single technique at our institution. Seven patients had single-stage bilateral procedures and 11 other patients had staged bilateral procedures. Indications for operation were first episode with prolonged air leak, incomplete lung reexpansion, or job restrictions (n = 59), first ipsilateral recurrence (n = 57), second or third ipsilateral recurrence (n = 34), contralateral recurrence (n = 25), synchronous bilateral pneumothorax (n = 3), hemopneumothorax (n = 3), and tension pneumothorax (n = 1). All patient data were reviewed retrospectively, and 167 patients were available for late follow-up (92%). RESULTS: Mean operative time was 57 +/- 19 minutes. Conversion to thoracotomy was required in 1 patient (0.6%). Mean duration of pleural drainage was 5.8 +/- 1.2 days (range, 4 to 26 days), and mean postoperative stay was 7.7 +/- 1.6 days (range, 6 to 31 days). Postoperative complications occurred in 50 patients (27.4%), the most frequent being prolonged air leak (14.8%), and in-hospital mortality was 0%. After a mean follow-up of 93 +/- 22 months (range, 57 to 134 months; median, 84 months), five ipsilateral recurrences were noted (3%). Three recurrences occurred within 12 months of videothoracoscopy and required reoperation. Two patients had partial pneumothorax recurrence at 39 and 58 months, and were treated conservatively with chest tube insertion and tale slurry. After 1 year, 10.7% of patients complained of chronic chest pain or discomfort, although none was taking pain medication after 3 months. Most patients (89.8%) were satisfied or very satisfied of their operation. All patients had returned to sport activities within 2 years. CONCLUSIONS: Videothoracoscopic bullectomy and pleural abrasion is a reliable and safe method to treat primary spontaneous pneumothorax. Long-term recurrences occur with an acceptable rate that compares with results after limited thoracotomy. Chronic chest pain or discomfort is unpredictable and may represent a problem in a few patients.     

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.     

Lung wedge resection improves outcome in stage I primary spontaneous pneumothorax

BACKGROUND: To evaluate the role of apical lung wedge resection in patients with recurrent primary spontaneous pneumothorax with no endoscopic abnormalities at surgery as compared with simple apical pleurectomy. METHODS: We performed a retrospective analysis on 126 consecutive video-assisted thoracoscopic surgery (VATS) procedures in 113 patients treated for stage I recurrent PSP between January 1994 and December 2001. Two surgical strategies were applied: simple apical pleurectomy (57 procedures, 45.2%: group A) and apical pleurectomy together with an apical lung wedge resection (69 procedures, 54.8%: group B). RESULTS: Mean duration of chest tubes was 1.4 days (range, 1 to 7), mean hospital stay was 2.4 days. Three patients (2.4%) required redo VATS, 2 in group A (3.5%) for persistent air leak and 1 (1.4%) in group B for apical hematothorax. Mean follow-up was 38.7 months. Overall recurrence rate was 3.2%. Four patients in group A (7%) experienced recurrent ipsilateral pneumothoraces 4 to 73 weeks (mean, 30.2) after surgery. No recurrences were observed in group B (p = 0.009). CONCLUSIONS: In this selected group of patients without endoscopical abnormalities, VATS offers low recurrence rates. However, these data suggest that apical pleurectomy should be accompanied by apical lung wedge resection even for this favorable category of patients.     

Occurrence of a simultaneous bilateral spontaneous pneumothorax due to a pleuro-pleural communication

Herein we present a case of a simultaneous bilateral spontaneous pneumothorax caused by a pleuro-pleural communication. A 70-year-old man with a history of esophagectomy presented with dyspnea. A chest roentgenogram revealed a bilateral pneumothorax and bilateral chest drainage procedures were performed. A left bullectomy was also performed 3 days later due to persistent air leakage on the left side. During surgery, a small fistula was detected in the anterior mediastinal pleura and was found to be in communication with the bilateral pleural spaces.     

Simultaneous bilateral spontaneous pneumothorax with pleural window communicating with bilateral pleural spaces

A pleural window communicating between bilateral pleural cavities is a serious condition in patients with pneumothorax, allowing air to leak from the affected lung into the contralateral pleural cavity and resulting in bilateral spontaneous pneumothorax. We treated a patient with a history of right-sided bullectomy for simultaneous bilateral spontaneous pneumothorax that subsequently recurred. A pleural window (1 cm long) was detected in the mid-mediastinum, and direct suture closure with localized pleural abrasion using argon beam coagulation on the circumference of the lesion was performed at video-assisted thoracoscopic surgery.     

Management of spontaneous pneumothorax using a Heimlich flutter valve

Intrapleural evacuation of air was achieved with a Heimlich flutter (non-return) valve in 16 patients with a total of 18 pneumothoraces, 17 of which were spontaneous. Complete lung expansion occurred in 17 (94·4%) of these episodes by five days, and 12 (66%) showed full expansion within one hour. Valve blockage occurred in one patient whose pneumothorax was associated with exudation through the intrapleural catheter and standard under water drainage is recommended in this situation or where there is effusion.     

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.     

Limits of duration of chest tube drainage in the first episode of spontaneous pneumothorax]

We treated three patients with spontaneous left pneumothorax who underwent a long period of chest tube drainage before surgery. Case 1 was a 61-year-old man. On day 13 after drainage started, much air leakage occurred and surgery was done the next day. Case 2 was a 57-year-old man. Drainage failed to allow the air leakage to seal. The patient did not consent to surgery for about a month, but on day 38 after drainage started, he underwent surgery. Case 3 was a 19-year-old man. First, chest tube drainage was successful and he was extubated on day 16. However, pneumothorax recurred the next day. Liver dysfunction delayed surgical treatment, and the patient underwent surgery on day 54 after the first drainage. Postoperatively, he developed wound infection of the chest tube route and aseptic pleurisy of unknown origin. Limits of duration of unsuccessful chest tube drainage for the first episode of spontaneous pneumothorax are controversial. These cases suggest that when two weeks of chest tube drainage is unsuccessful, surgery should be undertaken in view of postoperative complication and social indications.     

Catamenial pneumothorax: retrospective study of surgical treatment

BACKGROUND: Catamenial pneumothorax is a rare entity characterized by recurrent accumulation of air in the thoracic space during menstruation. Catamenial pneumothorax is also associated with a high rate of postoperative recurrence. The aim of this study was to discuss the etiology and to determine the optimal surgical treatment of this entity. METHODS: From December 1991 to September 2000, 10 patients with catamenial pneumothorax were treated at our institution. Median age at time of operation was 37 years (range, 21 to 44 years). We retrospectively evaluated the pathologic findings, the operation performed, and the results in all patients. The mean follow-up was 55.7 months. RESULTS: Pleurodesis alone was performed in 5 patients and an associated diaphragmatic procedure was performed in 5 patients. In 5 patients, no diaphragmatic anomaly was discovered: 3 experienced one or more recurrences and all still suffer from chronic catamenial chest pain. Hormonal therapy temporarily improved outcome for 6 months in 2 patients. On the contrary, in 5 patients surgical pleurodesis was associated with the repair of diaphragmatic defects (simple closure or coverage by a polyglactin mesh): these patients experienced no recurrence (n = 0/5, p = 0.0016) and no subsequent catamenial chest pain. CONCLUSIONS: The postoperative outcome is influenced by the diagnosis of diaphragmatic defects with or without endometriosis. Surgical treatment should be accomplished during menstruation for an optimal visualization of pleurodiaphragmatic endometriosis. Because diaphragmatic lesion is frequent and may be occult, we propose the systematic coverage of the diaphragmatic surface by a polyglactin mesh to prevent catamenial pneumothorax recurrence even when the diaphragm appears normal.