Spontaneous pneumothorax, primary or secondary, is a common medical emergency for which specific indications for surgical intervention are well defined in selected patients. The traditional surgical approach has been by limited thoracotomy using axillary or posterolateral incision. With the advent of video-assisted minimally invasive technique in the last 20 years the traditional approach is infrequently used. The definitive operation to prevent recurrent pneumothorax by surgical approach requires bullectomy and parietal pleurectomy. The recurrence rate after the traditional open surgical approach has been low at <2%. On the other hand, video-assisted thoracoscopic surgery, although better tolerated has a higher recurrence rate at 5% [1]. Information on post-operative morbidity and mortality are lacking. For this reason, we have reviewed our experience at one institution on the outcome of the VATS approach. We found that prolonged post- operative air leak is the most common complication and cigarette smoking remains an important associated factor.
Video Assisted Thoracic Surgery (VATS) is considered the gold standard surgical technique for the treatment of pneumothorax. To resect blebs or bullae and to achieve satisfactory pleurodesis, several techniques have been described. Minimally invasive technique using staplers to remove bullous parenchyma is the popular method by the majority of thoracic surgeons. Other techniques to perform bullectomy include endoscopic suturing [
From 2008 to 2014, 161 patients required bullectomy and pleurectomy by open or VATS due to pneumothoraces at the Ottawa Hospital, Canada. Inclusion criteria for our study were any patient that had a spontaneous recurrent pneumothorax, first tension spontaneous pneumothorax and first pneumothorax associated with prolonged air leak (defined as air leak more than five days) and were treated with VATS approach. Exclusion criteria were patients with secondary pneumothoraces treated with VATS bullectomy and pleurectomy or those who underwent a thoracotomy. The operations were performed by one of six surgeons in the department of Thoracic surgery at the Ottawa Hospital. Preoperative investigations included blood work, chest radiographs and a computed tomographic scan of the thorax in the majority of the cases (some of the patients were taken to the operating room without a CT chest). Data was collected retrospectively for all patients and included a detailed history, age, sex, smoking habits, comorbidities, treatment modalities, and surgical details. The postoperative variables assessed included postoperative complications, duration of chest tube drainage, length of hospital stay as well as a follow up for the patients up to 2 years.
The operations were performed under general anesthesia; lung isolation was achieved by using a double lumen intubation. A 1-cm incision was performed above the diaphragm level which is used as the camera port. The camera is inserted through that port and a thorough inspection is performed. Two further 1-cm incisions anterior and posterior to the tip of the scapula in the fifth intercostal spaceis performed. If blebs or bullaes were found, they were grasped and excised with an endo GIA stapling device with either a single or multiple fires. Partial pleurectomy was then performed by incising the parietal pleura starting at the level of the anterior trocar up to the level of the second rib and back to the level of the posterior trocar. A grasper is used to peel off the parietal pleura. An air leak test was performed under a pressure loading of 20 cm H2O. Two chest tubes were placed through the port sites.
After the operation, patients were extubated in the operating room and transferred to the recovery room. A perioperative intercostal nerve block was used in addition to patient-controlled analgesia (PCA) system after the operation. This was continued until oral analgesia was commenced on as and when needed.
Continuous suction is applied for the first 48 hours. Chest tubes were removed when the underlying lung was fully expanded with no residual air leak and minimal fluid drainage. Patients were discharged from the hospital when they were fully mobile and when their pain was controlled by oral analgesia.
Patients were seen 3 to 4 weeks post-operatively unless if they were discharged from the hospital with a chest tube attached to a pneumostat due to prolonged air leak, in that case they were seen one week after discharge. Chest X rays were performed at all visits. On follow-up examination, patients were assessed for any signs or symptoms or radiologic features suggesting recurrent pneumothorax. Assessment of wound healing as well as Information regarding complications was also obtained.
All patients details were interred in the Standardized Monitoring of Post-Operative Morbidity and Mortality for the Evaluation of Thoracic Surgical Quality TSQIC program, a data base system including names, date of birth, reason for admission, elective of urgent surgery, the type of surgery and any complications either during the admission or later after discharge.
All 161 patients were studied in this prospective review. One hundred and thirty-four underwent VATS bullectomy and pleurectomy for recurrent spontaneous pneumothorax. Average age was 33.8 (range 16 - 63). There were 96 male and 38 female patients. Comorbidities are listed in (
Comorbidity | Number of patients |
---|---|
Hypertension | 6 |
Obesity | 1 |
Diabetes | 1 |
Asthma | 2 |
Hypercholesterolemia | 1 |
CAD | 1 |
GERD | 2 |
Atrial fibrillation | 1 |
Polio | 1 |
Scoliosis | 1 |
TIA | 1 |
Osteochondromatosis | 1 |
Cerebral palsy | 1 |
Lymphoma | 1 |
Smoking | Number of patients |
---|---|
Active | 97 |
Never | 13 |
Ex-smoker | 24 |
All patients underwent bullectomy and pleurectomy. Bullectomy was performed in all patients, even when the bleb or bullae were not found, a wedge resection of the apex of the upper lobe was performed. There were no unpleasant events. The blebs and/or bullae were found in 112 (83.5%) patient. Average blood loss was less than 100 mL in 129 (96%) of the cases. Air leak testing before closure was satisfactory in all cases. All specimens were sent for pathological analysis. There was no correlation found between the pathological result and the occurrence of complications.
The average hospital stay was 4.6 days (range from 2 to 21). The complication rate was 32%. This includes (
On follow up, 118 (88%) patients were followed up to 2 years post operatively and 16 patients didn’t show up in clinic. Follow up was ranged from minimally one time to maximum four times for a patient depending on if the recovery was straight forward or there was a complication (mainly the prolonged air leak for chest tube removal). Amongst those who were followed 65.2% (n = 77) were satisfied and they presented with no problems. Eighteen patients were discharged from the hospital with chest tubes because of having a prolonged air leak and
Number of episodes | Number of patients |
---|---|
1 | 65 |
2 | 55 |
3 | 8 |
4 | 3 |
Complications | Number of patients (%) |
---|---|
Prolonged air leak | 21 (15.6%) |
Pneumothorax | 10 (7.4%) |
Empyema | 5 (3.7%) |
Pneumonia | 4 (2.9%) |
Pleural effusion | 2 (1.4%) |
Wound infection | 2 (1.4%) |
Subcutaneous emphysema | 1 (0.7%) |
Atrial fibrillation | 1 (0.7%) |
Hemothorax | 1 (0.7%) |
they were followed for that reason, chest tubes were removed when there were no more air leak and the lung was fully expanded on chest X-ray. Nineteen patients (16%) complained of neuropathic pain which was controlled with oral analgesics and 6 patients (5%) were still complaining of mild dyspnea on exertion.
Spontaneous pneumothorax (SP) is one of the common problems that the thoracic surgeon face in his or her practice. The rate of recurrence is 20% after a first episode, 60% after a second, and 80% after a third [
The traditional operation was by limited thoracotomy using axillary or posterolateral approach. Currently, VATS has been increasingly used. There was always a controversy regarding the best treatment, either to manage surgically by open or VATS techniques.
Evidence from randomized controlled trials regarding the advantages associated with VATS for the treatment of pneumothorax seems to be similar for other advantages associated with other minimally invasive thoracic surgeries for other reasons. Most of these studies reported less surgery time, lower use of pain medication, and lower length of hospital stay [
Horio et al. found that patients operated on with VATS had higher recurrences compared to patients operated on with thoracotomy. They suggested that these differences could be explained by undetected bullae in the VATS group [
Other authors have also recommended wedge resection of the apex in all cases [
In a recent multicenter cohort study, they reported successful video assisted thoracic surgery for pneumothorax in 714 patients over a period of two years [
In a review about the recurrence rate of pneumothorax with randomized and non-randomized trials, Barker et al. report that the recurrence of pneumothorax, when the same pleurodesis procedure is performed, is four-fold increased after VATS approaches rather than open approaches [
In the literature review there were some postoperative cases of death reported [
Bleeding requiring reoperation has been reported by some authors [
It must be underlined that, besides cases of re-operation, all authors report prolonged air leak, which is the most common postoperative complication. Other morbidities reported in literature are: pneumonia, atelectasis, needing of mechanical ventilation, wound infections, empyema, pleural effusion, ARDS and Horner’s syndrome [
Uramoto et al. [
In a recent review jean-Philippe Delpy et al. on 7647 patients in France hospitals to detect the prognostic factors influencing postoperative complications for spontaneous pneumothorax [
To evaluate the quality of life after surgical treatment of pneumothorax Ben-Nun et al. compared VATS and limited thoracotomy. They observed that patients in the thoracotomy group needed significantly higher doses of narcotic analgesia for a longer period than patients in the VATS group [
The recurrence rate after VATS treatment for pneumothorax was very low (between 0% and 5.8%) [
Chronic pain and chest wall paresthesia one year after the procedure have been reported in about 21% of the patients [
VATS bullectomy and pleurectomy is now the preferred surgical approach for treatment of recurrent spontaneous pneumothorax with a reasonable low recurrence rate. Prolonged air leak and the recurrence of pneumothorax are the most common post-operative complication. Smoking was found to be a risk factor for post-operative complications and therefore smoking cessation is important in improving outcome. Further studies with prospective data collection are needed to verify our results.
Ramzi A. Addas,Farid M. Shamji,Sudhir R. Sundaresan,Patrick James Villeneuve,Andrew J. E. Seely,Sebastien Gilbert,Donna E. Maziak, (2016) Is VATS Bullectomy and Pleurectomy an Effective Method for the Management of Spontaneous Pneumothorax?. Open Journal of Thoracic Surgery,06,25-31. doi: 10.4236/ojts.2016.63005