Pleural Abrasion for Mechanical Pleurodesis in Surgery for Primary Spontaneous Pneumothorax: Is it Effective?

Joint ERS/EACTS/ESTS clinical practice guidelines on adults with spontaneous pneumothorax

OBJECTIVES

The optimal management for spontaneous pneumothorax (SP) remains contentious, with various proposed approaches. This joint clinical practice guideline from the ERS, EACTS and ESTS societies provides evidence-based recommendations for the management of SP.

METHODS

This multidisciplinary Task Force addressed 12 key clinical questions on the management of pneumothorax, using ERS methodology for guideline development. Systematic searches were performed in MEDLINE and Embase. Evidence was synthesised by conducting meta-analyses, if possible, or narratively. Certainty of evidence was rated with GRADE (Grading, Recommendation, Assessment, Development and Evaluation). The Evidence to Decision framework was used to decide on the direction and strength of the recommendations.

RESULTS

The panel makes a conditional recommendation for conservative care of minimally symptomatic patients with primary spontaneous pneumothorax (PSP) who are clinically stable. We make a strong recommendation for needle aspiration over chest tube drain for initial PSP treatment. We make a conditional recommendation for ambulatory management for initial PSP treatment. We make a conditional recommendation for early surgical intervention for the initial treatment of PSP in patients who prioritise recurrence prevention. The panel makes a conditional recommendation for autologous blood patch in secondary SP patients with persistent air leak (PAL). The panel could not make recommendations for other interventions, including bronchial valves, suction, pleurodesis in addition to surgical resection or type of surgical pleurodesis.

CONCLUSIONS

With this international guideline, the ERS, EACTS and ESTS societies provide clinical practice recommendations for SP management. We highlight evidence gaps for the management of PAL and recurrence prevention, with research recommendations made.

SHAREABLE ABSTRACT

This update of an ERS Task Force statement from 2015 provides a concise comprehensive update of the literature base. 24 evidence-based recommendations were made for management of pneumothorax, balancing clinical priorities and patient views.https://bit.ly/3TKGp9e.

Joint ERS/EACTS/ESTS clinical practice guidelines on adults with spontaneous pneumothorax

BACKGROUND

The optimal management for spontaneous pneumothorax (SP) remains contentious, with various proposed approaches. This joint clinical practice guideline from the ERS, EACTS and ESTS societies provides evidence-based recommendations for the management of SP.

METHODS

This multidisciplinary Task Force addressed 12 key clinical questions on the management of pneumothorax, using ERS methodology for guideline development. Systematic searches were performed in MEDLINE and Embase. Evidence was synthesised by conducting meta-analyses, if possible, or narratively. Certainty of evidence was rated with GRADE (Grading of Recommendations, Assessment, Development and Evaluations). The Evidence to Decision framework was used to decide on the direction and strength of the recommendations.

RESULTS

The panel makes a conditional recommendation for conservative care of minimally symptomatic patients with primary spontaneous pneumothorax (PSP) who are clinically stable. We make a strong recommendation for needle aspiration over chest tube drain for initial PSP treatment. We make a conditional recommendation for ambulatory management for initial PSP treatment. We make a conditional recommendation for early surgical intervention for the initial treatment of PSP in patients who prioritise recurrence prevention. The panel makes a conditional recommendation for autologous blood patch in secondary SP patients with persistent air leak (PAL). The panel could not make recommendations for other interventions, including bronchial valves, suction, pleurodesis in addition to surgical resection or type of surgical pleurodesis.

CONCLUSIONS

With this international guideline, the ERS, EACTS and ESTS societies provide clinical practice recommendations for SP management. We highlight evidence gaps for the management of PAL and recurrence prevention, with research recommendations made.

Evaluating postoperative recovery in uniportal versus needlescopic video-assisted thoracoscopic surgery for primary spontaneous pneumothorax: a comparable study

Objectives

Primary spontaneous pneumothorax (PSP) is a common disease in young and thin male. Operation has been regarded as definitive treatment for it. However, the operative methods for those patients are under dispute. This study aims to directly compare the outcomes of uniportal VATS vs. needlescopic VATS in the treatment of PSP, focusing on postoperative pain and safety outcomes.

Methods

From July 2013 to December 2017, the patients who underwent video-assisted thoracic surgery for pneumothorax in National Taiwan University Hospital were retrospectively collected. The preoperative condition, surgical results, and postoperative outcomes was analyzed.

Results

There were 60 patients undergoing needlescopic VATS and 91 undergoing uniportal VATS during the study period. There was no significant difference between the patients who underwent needlescopic VATS and those who underwent uniportal VATS in their demographic and clinical characteristics. The post-operative pain score was significantly lower in the uniportal VATS group compared to the needlescopic VATS group at day 1 (2.65 ± 1.59 vs. 1.74 ± 1.35, p = 0.001).

Conclusion

Uniportal VATS offers an effective, safe alternative for PSP treatment, with benefits including reduced post-operative pain. Our findings support the use of uniportal VATS, supplemented by a wound protector, as a viable option for PSP patients.

Evaluation and Management of Primary Spontaneous Pneumothorax in Adolescents and Young Adults: A Systematic Review From the APSA Outcomes & Evidence-Based Practice Committee

INTRODUCTION

Controversy exists in the optimal management of adolescent and young adult primary spontaneous pneumothorax. The American Pediatric Surgical Association (APSA) Outcomes and Evidence-Based Practice Committee performed a systematic review of the literature to develop evidence-based recommendations.

METHODS

Ovid MEDLINE, Elsevier Embase, EBSCOhost CINAHL, Elsevier Scopus, and Wiley Cochrane Central Register of Controlled Trials databases were queried for literature related to spontaneous pneumothorax between January 1, 1990, and December 31, 2020, addressing (1) initial management, (2) advanced imaging, (3) timing of surgery, (4) operative technique, (5) management of contralateral side, and (6) management of recurrence. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were followed.

RESULTS

Seventy-nine manuscripts were included. Initial management of adolescent and young adult primary spontaneous pneumothorax should be guided by symptoms and can include observation, aspiration, or tube thoracostomy. There is no evidence of benefit for cross-sectional imaging. Patients with ongoing air leak may benefit from early operative intervention within 24-48 h. A video-assisted thoracoscopic surgery (VATS) approach with stapled blebectomy and pleural procedure should be considered. There is no evidence to support prophylactic management of the contralateral side. Recurrence after VATS can be treated with repeat VATS with intensification of pleural treatment.

CONCLUSIONS

The management of adolescent and young adult primary spontaneous pneumothorax is varied. Best practices exist to optimize some aspects of care. Further prospective studies are needed to better determine optimal timing of operative intervention, the most effective operation, and management of recurrence after observation, tube thoracostomy, or operative intervention.

LEVEL OF EVIDENCE

Level 4.

TYPE OF STUDY

Systematic Review of Level 1-4 studies.

SPLF/SMFU/SRLF/SFAR/SFCTCV Guidelines for the management of patients with primary spontaneous pneumothorax

INTRODUCTION

Primary spontaneous pneumothorax (PSP) is the presence of air in the pleural space, occurring in the absence of trauma and known lung disease. Standardized expert guidelines on PSP are needed due to the variety of diagnostic methods, therapeutic strategies and medical and surgical disciplines involved in its management.

METHODS

Literature review, analysis of the literature according to the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) methodology; proposals for guidelines rated by experts, patients and organizers to reach a consensus. Only expert opinions with strong agreement were selected.

RESULTS

A large PSP is defined as presence of a visible rim along the entire axillary line between the lung margin and the chest wall and ≥ 2 cm at the hilum level on frontal chest X-ray. The therapeutic strategy depends on the clinical presentation: emergency needle aspiration for tension PSP; in the absence of signs of severity: conservative management (small PSP), needle aspiration or chest tube drainage (large PSP). Outpatient treatment is possible if a dedicated outpatient care system is previously organized. Indications, surgical procedures and perioperative analgesia are detailed. Associated measures, including smoking cessation, are described.

CONCLUSION

These guidelines are a step towards PSP treatment and follow-up strategy optimization in France.

SPLF/SMFU/SRLF/SFAR/SFCTCV Guidelines for the management of patients with primary spontaneous pneumothorax: Endorsed by the French Speaking Society of Respiratory Diseases (SPLF), the French Society of Emergency Medicine (SFMU), the French Intensive Care Society (SRLF), the French Society of Anesthesia & Intensive Care Medicine (SFAR) and the French Society of Thoracic and Cardiovascular Surgery (SFCTCV)

INTRODUCTION

Primary spontaneous pneumothorax (PSP) is the presence of air in the pleural space, occurring in the absence of trauma and known lung disease. Standardized expert guidelines on PSP are needed due to the variety of diagnostic methods, therapeutic strategies and medical and surgical disciplines involved in its management.

METHODS

Literature review, analysis of literature according to the GRADE (Grading of Recommendation Assessment, Development and Evaluation) methodology; proposals for guidelines rated by experts, patients, and organizers to reach a consensus. Only expert opinions with strong agreement were selected.

RESULTS

A large PSP is defined as presence of a visible rim along the entire axillary line between the lung margin and the chest wall and ≥2 cm at the hilum level on frontal chest x-ray. The therapeutic strategy depends on the clinical presentation: emergency needle aspiration for tension PSP; in the absence of signs of severity: conservative management (small PSP), needle aspiration or chest tube drainage (large PSP). Outpatient treatment is possible if a dedicated outpatient care system is previously organized. Indications, surgical procedures and perioperative analgesia are detailed. Associated measures, including smoking cessation, are described.

CONCLUSION

These guidelines are a step towards PSP treatment and follow-up strategy optimization in France.

Recommandations formalisées d’experts pour la prise en charge des pneumothorax spontanés primaires

Introduction : Le pneumothorax spontané primaire (PSP) est un épanchement gazeux dans la cavité pleurale, survenant hors traumatisme et pathologie respiratoire connue. Des recommandations formalisées d'experts sur le sujet sont justifiées par les pluralités de moyens diagnostiques, stratégies thérapeutiques et disciplines médicochirurgicales intervenant dans leur prise en charge.

Méthodes : Revue bibliographique, analyse de la littérature selon méthodologie GRADE (Grading of Recommendation Assessment, Development and Evaluation) ; propositions de recommandations cotées par experts, patients et organisateurs pour obtenir un consensus. Seuls les avis d'experts avec accord fort ont été retenus.

Résultats : Un décollement sur toute la hauteur de la ligne axillaire et supérieur ou égal à 2 cm au niveau du hile à la radiographie thoracique de face définit la grande abondance. La stratégie thérapeutique dépend de la présentation clinique : exsufflation en urgence pour PSP suffocant ; en l'absence de signe de gravité : prise en charge conservatrice (faible abondance), exsufflation ou drainage (grande abondance). Le traitement ambulatoire est possible si organisation en amont de la filière. Les indications, procédures chirurgicales et l'analgésie périopératoire sont détaillées. Les mesures associées, notamment le sevrage tabagique, sont décrites.

Conclusion : Ces recommandations sont une étape de l'optimisation des stratégies de traitement et de suivi des PSP en France.

Significance of very-low-voltage coagulation plus coverage with polyglycolic acid sheet after bullectomy for primary spontaneous pneumothorax

BACKGROUND

The purpose of this study was to clarify the efficacy of the combination of low-voltage coagulation plus staple line coverage with a polyglycolic acid sheet after bullectomy for primary spontaneous pneumothorax to prevent a postoperative recurrence.

METHODS

A total of 143 patients who underwent bullectomy for primary spontaneous pneumothorax between January 2014 and December 2019 were enrolled in this study. We classified the patients into two groups based on additional procedures after bullectomy, namely, low-voltage coagulation for the margin of the staple line plus coverage with a polyglycolic acid sheet (Group A) and staple line coverage with a polyglycolic acid sheet alone (Group B). We evaluated perioperative factors and recurrence-free survival after surgery in the two groups.

RESULTS

Nine patients in Group B developed postoperative recurrences. In contrast, there was no postoperative recurrence in Group A. According to the Kaplan-Meier curves, the 2-year recurrence-free survival rates of the patients were 100% and 90.3%, in Group A and Group B, respectively. The log-rank test showed a significant difference between the two groups (p = 0.031).

CONCLUSION

Low-voltage coagulation for the margin of a staple line plus coverage with a polyglycolic acid sheet is a useful option as an additional technique after bullectomy for primary spontaneous pneumothorax to prevent a postoperative recurrence.

Systematic review and meta-analysis on juvenile primary spontaneous pneumothorax: Conservative or surgical approach first?

Background

Primary spontaneous pneumothorax (PSP) prevalence is typically higher in juvenile patients than in adults. We aimed to evaluate the optimal treatment for primary spontaneous pneumothorax and its efficacy and safety in juveniles.

Materials and methods

We searched PubMed, Embase, and Cochrane databases for eligible studies published from database inception to October 10, 2020, and conducted a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The primary and secondary outcomes were recurrence rate and hospital stay length, respectively. Odds ratios (OR) and mean differences were used for quantitatively analyzing binary and continuous outcomes, respectively. In total, nine retrospective studies with 1,452 juvenile patients (aged <21) were included for the quantitative analysis. The surgical approach led to a lower recurrence rate than did conservative approaches (OR: 1.95, 95% confidence interval: 1.15–3.32). Moreover, the recurrence rate was low in patients who underwent conservative treatment first and received surgery later.

Conclusions

Surgical approach for first-line management might have a greater effect on recurrence prevention than do conservative approaches. An upfront surgery might be an optimal choice for juvenile primary spontaneous pneumothorax.

C-shaped pleura cautery in primary spontaneous pneumothorax patients for pleurodesis

Background:

Although pleurodesis is usually used to reduce the recurrence rate for primary spontaneous pneumothorax (PSP) in surgery, existing techniques cannot meet the higher requirements of little surgical injury and less relapse. Hence, we developed a new pleurodesis technique and named multipoint pleura cautery.

Aim:

In this study, we aimed to investigate the effectiveness and outcomes of the uniportal video-assisted thoracoscopic surgery C-shaped pleura cautery in the surgical treatment of PSP. To the best of our knowledge, this is a new surgical technique for pleurodesis and must be of concern.

Patients and Methods:

The medical records of 20 patients undergoing surgery for C-shaped pleura cautery between 2015 and 2017 were reviewed. The patients were evaluated with regard to age, gender, body mass index, smoking habit, operation time, duration of hospitalization, post-operative pain and follow-up.

Results:

We have performed a bullectomy combined C-shaped pleura cautery for 20 patients with PSP from January 2016 to December 2017. None of the patients suffered post-operative bleeding and haematothorax complications, and one was ipsilateral relapsed 5 months after surgery. The lung computed tomography showed that recurrence of pneumothorax was due to air leakage in the right lower lung, and there was no air leakage at the site where pleurodesis had been performed.

Conclusions:

Although this technique requires further investigation, it may be a useful method of pleurodesis.

New options for pneumothorax management

Introduction: Pneumothorax is defined as the presence of air in the pleural space. Spontaneous pneumothorax, occurring without antecedent traumatic or iatrogenic cause, is classified as primary or secondary. There are substantial inconsistencies in international guidelines for the treatment of pneumothorax. Moreover, many geographical variations exist in daily clinical practice.Areas covered: In this article, we focus on novel treatment modalities for this significant health problem in young adults.Expert opinion: In part, these discrepancies have been caused by the lack of high-quality trials or evidence. Currently, the pathophysiological mechanisms underlying pneumothorax are better understood and have implications for clinical management. Studies have demonstrated that the judicious use of pleurodesis can decrease its rate of recurrence, both in surgical and nonsurgical patients.

The Evolution of Surgical Management for Children and Young Adults With Spontaneous Pneumothorax

BACKGROUND

Few studies have analyzed pediatric spontaneous pneumothorax (SPTX) nationally. We sought to better define this patient population and explore the evolution of surgical management.

METHODS

Patients (10-20 y old) with an International Classification of Diseases, Ninth Revision diagnosis of SPTX were identified within the Kids' Inpatient Database for the years 2006, 2009, and 2012. Diagnoses and procedures were analyzed by International Classification of Diseases, Ninth Revision codes. National estimates were obtained using case weighting.

RESULTS

There were 11,792 pediatric SPTX hospitalizations, and patients were predominantly male (84.0%), non-Hispanic white (69.0%), with a mean age of 17.2 y (95% confidence interval, 17.2-17.3). Overall, 52.5% underwent tube thoracostomy as the primary intervention, and more than one-third had a major surgical procedure (34.9%). From 2006 to 2012, there was an increase in bleb excisions from 81.1% to 86.9% and an increase in mechanical pleurodesis from 64.2% to 69.0%. There was a significant change from a predominantly open thoracotomy approach in 2006 (76.1%) to a video-assisted thoracoscopic approach in 2012 (89.3%).

CONCLUSIONS

Pediatric admission for SPTX results in tube thoracostomy in more than half of the cases and surgery in approximately one-third of the cases. Surgical intervention has changed to a more minimally invasive approach during the last decade, and counseling to patients and their families should reflect these updated management strategies.

LEVEL OF EVIDENCE

III.

Surgical Treatment of Spontaneous Pneumothorax: Pleural Abrasion or Pleurectomy?

PURPOSE

A primary spontaneous pneumothorax is a condition that occurs predominantly in young and thin male individuals who do not have any history of underlying lung disease. Various techniques such as pleural abrasion and pleurectomy are used to reduce the recurrence rate, but there exists no consensus among surgeons on which surgical technique offers the lowest risk of recurrence.We aimed to compare the efficiency and recurrence risk of pleural abrasion and pleurectomy methods in patients with primary spontaneous pneumothorax undergoing a wedge resection for the bulleous part of the paranchyme.

MATERIALS AND METHODS

Statistically compared variables between the 2 groups were age, sex, symptoms, smoking status, number of previous pneumothorax episodes, surgical indication, bleb number, estimated blood loss, intraoperative complication, duration of the surgery, conversion to open surgery, postoperative drainage amount, chest tube removal time, length of hospital stay, morbidity, mortality, duration of narcotic analgesic usage, pain according to Visual Analog Scale evaluation, follow-up period, and postoperative recurrence.

RESULTS

The medical records of 88 patients undergoing surgery between 2013 and 2017 were reviewed retrospectively. The pleural abrasion group was superior to the pleurectomy group in terms of operation time, drainage volume, time to drain removal, hospital stay, and Visual Analog Scale pain score on postoperative day 0. Statistically, there was no difference between the pleural abrasion group and the pleurectomy group in the recurrence rates after operation (2.0% vs. 2.5%, respectively; P=0.89).

CONCLUSIONS

Thoracoscopic pleural abrasion is safer than apical pleurectomy and is associated with the same pneumothorax recurrence rate.

Pleural abrasion should not routinely preferred in treatment of primary spontaneous pneumothorax

BACKGROUND

The aim of this study was to find out whether thoracoscopic bullectomy with pleural abrasion (BLPA) could lower the recurrence ratio in primary spontaneous pneumothorax (PSP) patients compared with bullectomy alone.

METHODS

All PSP patients who underwent video assisted thoracoscopy (VATS) bullectomy (120 bullectomy cases) or BLPA (225 BLPA cases) in our department between 2008.1 and 2013.12 were retrospectively reviewed. Clinical data, perioperative data, and follow-up information were collected. Propensity score analysis was used in balancing preoperative factors between groups.

RESULTS

Three hundred and forty five patients (283 men and 62 women) with an average age of 27 (27.32±11.41) years old underwent 120 bullectomy and 225 BLPA in this study. There was no mortality or significant complication in both groups. More postoperative drainage (1,170.66±904.02 vs. 528.38±491.49, P<0.01), longer chest tube removal days (6.59±4.29 vs. 4.76±2.67, P<0.01), and more medical cost (4,703.86±1,526.31 vs. 4,204.64±1,203.90, P<0.01) were observed in BLPA group. Significant difference (P=0.02) existed in recurrence rate between BLPA group (3/225, 1.3%) and bullectomy group (7/120, 5.8%). After propensity score match, 114 patients were included in both bullectomy and BLPA groups. More postoperative drainage (1,280.18±1,071.04 vs. 523.55±484.79, P<0.01), longer chest tube removal days (6.53±4.16 vs. 4.69±2.63, P<0.01), and more medical cost (4,700.69±1,591.56 vs. 4,211.45±1,207.7, P<0.01) were observed in BLPA group. There was no significant recurrence difference between BLPA group and bullectomy group (2.6% vs. 5.3%, P=0.30).

CONCLUSIONS

Compared with bullectomy, BLPA could provide similar recurrence for PSP patients, but at the price of longer operation days, longer chest tube removal days, and more medical cost, and should not be performed in PSP patients.

Learning curve of single-incision thoracoscopic surgery for primary spontaneous pneumothorax

BACKGROUND

Single-incision thoracoscopic surgery (SITS) requires extensive time and practice to achieve satisfactory technical skills. The aim of this study was to evaluate the learning curves of SITS for primary spontaneous pneumothorax (PSP).

METHODS

This study included a total of 274 consecutive patients who underwent PSP surgery by a single operator between May 2011 and February 2014. During this period, SITS was applied as a routine approach. Learning curves were made by the cumulative sum (CUSUM) method using the number of cases and four surgical technique-related factors, including operation time, postoperative complication, non-SITS rate, and ipsilateral PSP recurrence.

RESULTS

Among the 274 patients, 16 patients who were presented with a previous 3-port wound scar or inadequate chest tube site before surgery were not eligible for SITS. Hence, SITS was attempted on 258 patients and performed successfully in 251 patients. For these successful SITS patients, the mean age was 22.9 ± 8.1 years, the mean operation time was 65.6 ± 22.2 min, the mean chest tube indwelling time was 1.5 ± 1.1 days, and the mean postoperative hospital stay was 1.7 ± 1.1 days. The mean operation time decreased from 84.0 to 47.6 min when a comparison was made between patients operated in the initial 6 months and the last 6 months of the study period. As revealed by the CUSUM technique, more than 50 % of the cases experienced an operation time of <70 min after the first 92 cases. After 57 cases, the postoperative complication rate was maintained at <5 %. The non-SITS rate was achieved to be lower than 5 % after 112 cases. The ipsilateral PSP recurrence rate was maintained at below 8 % after 102 cases.

CONCLUSIONS

Although PSP is the most applicable scenario for the beginner of SITS, at least 100 cases of experience are needed to achieve optimal technical level.

Single-port thoracoscopic surgery for pneumothorax under two-lung ventilation with carbon dioxide insufflation

BACKGROUND

The development of single-port thoracoscopic surgery and two-lung ventilation reduced the invasiveness of minor thoracic surgery. This study aimed to evaluate the feasibility and safety of single-port thoracoscopic bleb resection for primary spontaneous pneumothorax using two-lung ventilation with carbon dioxide insufflation.

METHODS

Between February 2009 and May 2014, 130 patients underwent single-port thoracoscopic bleb resection under two-lung ventilation with carbon dioxide insufflation. Access was gained using a commercial multiple-access single port through a 2.5-cm incision; carbon dioxide gas was insufflated through a port channel. A 5-mm thoracoscope, articulating endoscopic devices, and flexible endoscopic staplers were introduced through a multiple-access single port for bulla resection.

RESULTS

The mean time from endotracheal intubation to incision was 29.2±7.8 minutes, the mean operative time was 30.9±8.2 minutes, and the mean total anesthetic time was 75.5±14.4 minutes. There were no anesthesia-related complications or wound problems. The chest drain was removed after a mean of 3.7±1.4 days and patients were discharged without complications 4.8±1.5 days from the operative day. During a mean 7.5±10.1 months of follow-up, there were five recurrences (3.8%) in operated thorax.

CONCLUSIONS

The anesthetic strategy of single-lumen intubation with carbon dioxide gas insufflation can be a safe and feasible option for single-port thoracoscopic bulla resection as it represents the least invasive surgical option with the potential advantages of reducing operative time and one-lung ventilation-related complications without diminishing surgical outcomes.

Primary spontaneous pneumothorax: simultaneous treatment by bilateral non-intubated videothoracoscopy

OBJECTIVES

Through a retrospective study, we assessed the feasibility and safety of simultaneous bilateral thoracoscopic wedge resection of blebs or bullae for the treatment of primary spontaneous pneumothorax (PSP) under thoracic epidural anaesthesia with spontaneous ventilation.

METHODS

This retrospective analysis involved a cohort of 37 consecutive patients undergoing simultaneous bilateral thoracoscopic bullectomy under spontaneous ventilation thoracic epidural anaesthesia (n = 15) or intubated general anaesthesia (n = 22) between July 2011 and September 2015. The perioperative data, short-term outcomes and recurrence rates of the two groups were compared.

RESULTS

The two groups had comparable preoperative demographic profiles. There were no conversions to thoracotomy or intubated single-lung ventilation. The peak end-tidal carbon dioxide in the non-intubated group was significantly higher than that in the intubated group (mean: 48 vs 34 mmHg, P < 0.001). Both groups had comparable surgical duration, blood loss and lowest intraoperative pulse oxygen saturation level. Postoperatively, the two groups had comparable chest tube duration, volume of fluid administration, length of hospital stay and complication rates. No mortality occurred. The total anaesthesia cost in non-intubated group was significantly lower (mean: CNY 4584 vs 5649, P = 0.016). The mean follow-up was 23.6 ± 12.9 months in the non-intubated group and 21.1 ± 13.4 months in the intubated group. Two recurrent pneumothoraxes in 2 patients were observed after surgical procedures for PSP. One recurrence developed in the non-intubated group (7%) and one in the intubated group (5%).

CONCLUSIONS

Simultaneous bilateral non-intubated thoracoscopic bullectomy is not only well tolerated and technically feasible but also a safe alternative for selected patients with simultaneous bilateral PSP or with high risk of contralateral recurrence.

Staple Line Coverage with a Polyglycolic Acid Patch and Fibrin Glue without Pleural Abrasion after Thoracoscopic Bullectomy for Primary Spontaneous Pneumothorax

Background

This study was conducted to determine the efficacy of staple line coverage using a polyglycolic acid patch and fibrin glue without pleural abrasion to prevent recurrent postoperative pneumothorax.

Methods

A retrospective analysis was carried out of 116 operations performed between January 2011 and April 2013. During this period, staple lines were covered with a polyglycolic acid patch and fibrin glue in 58 cases (group A), while 58 cases underwent thoracoscopic bullectomy only (group B).

Results

The median follow-up period was 33 months (range, 22 to 55 months). The duration of chest tube drainage was shorter in group A (group A 2.7±1.2 day vs. group B 3.9±2.3 day, p=0.001). Prolonged postoperative air leakage occurred more frequently in group B than in group A (43% vs. 19%, p=0.005). The postoperative recurrence rate of pneumothorax was significantly lower in group A (8.6%) than in group B (24.1%) (p=0.043). The total cost of treatment during the follow-up period, including the cost for the treatment of postoperative recurrent pneumothorax, was not significantly different between the two groups (p=0.43).

Conclusion

Without pleural abrasion, staple line coverage with a medium-sized polyglycolic acid patch and fibrin glue after thoracoscopic bullectomy for primary spontaneous pneumothorax is a useful technique that can reduce the duration of postoperative pleural drainage and the postoperative recurrence rate of pneumothorax.

ERS task force statement: diagnosis and treatment of primary spontaneous pneumothorax

Primary spontaneous pneumothorax (PSP) affects young healthy people with a significant recurrence rate. Recent advances in treatment have been variably implemented in clinical practice. This statement reviews the latest developments and concepts to improve clinical management and stimulate further research.The European Respiratory Society's Scientific Committee established a multidisciplinary team of pulmonologists and surgeons to produce a comprehensive review of available scientific evidence.Smoking remains the main risk factor of PSP. Routine smoking cessation is advised. More prospective data are required to better define the PSP population and incidence of recurrence. In first episodes of PSP, treatment approach is driven by symptoms rather than PSP size. The role of bullae rupture as the cause of air leakage remains unclear, implying that any treatment of PSP recurrence includes pleurodesis. Talc poudrage pleurodesis by thoracoscopy is safe, provided calibrated talc is available. Video-assisted thoracic surgery is preferred to thoracotomy as a surgical approach.In first episodes of PSP, aspiration is required only in symptomatic patients. After a persistent or recurrent PSP, definitive treatment including pleurodesis is undertaken. Future randomised controlled trials comparing different strategies are required.

The effect of pleural abrasion on the treatment of primary spontaneous pneumothorax: a systematic review of randomized controlled trials

BACKGROUND

Pleural abrasion has been widely used to control the recurrence of primary spontaneous pneumothorax (PSP). However, controversy still exists regarding the advantages and disadvantages of pleural abrasion compared with other interventions in preventing the recurrence of PSP.

METHODS

The PubMed, Embase, and Cochrane Central Register of Controlled Trials databases were searched up to December 15, 2014 to identify randomized controlled trials (RCTs) that compared the effects of pleural abrasion with those of other interventions in the treatment of PSP. The study outcomes included the PSP recurrence rate and the occurrence rate of adverse effects.

RESULTS

Mechanical pleural abrasion and apical pleurectomy after thoracoscopic stapled bullectomy exhibited similarly persistent postoperative air leak occurrence rates (p = 0.978) and 1-year PSP recurrence rates (p = 0.821), whereas pleural abrasion led to reduced residual chest pain and discomfort (p = 0.001) and a smaller rate of hemothorax (p = 0.036) than did apical pleurectomy. However, the addition of minocycline pleurodesis to pleural abrasion did not reduce the pneumothorax recurrence rate compared with apical pleurectomy (3.8% for both procedures) but was associated with fewer complications. There was no statistical difference in the pneumothorax recurrence rate between mechanical pleural abrasion and chemical pleurodesis with minocycline on either an intention-to-treat basis (4 of 42 versus 0 of 42, p = 0.12; Fisher exact test) or after exclusions (2 of 40 versus 0 of 42, p = 0.24; Fisher exact test). Pleural abrasion plus minocycline pleurodesis also did not reduce the pneumothorax recurrence rate compared with pleural abrasion alone (p = 0.055). Moreover, pleural abrasion plus minocycline pleurodesis was associated with more intense acute chest pain. The postoperative overall recurrence rate in patients who underwent staple line coverage with absorbable cellulose mesh and fibrin glue was similar to that with mechanical abrasion after thoracoscopic bullectomy (13.8% vs. 14.2%, respectively; p = 0.555), but staple line coverage resulted in less postoperative residual pain than mechanical abrasion (0.4% vs.3.2%; p<0.0001). Pleural abrasion after thoracoscopic wedge resection did not decrease the recurrence of pneumothorax compared with wedge resection alone (p = 0.791), but the intraoperative bleeding and postoperative pleural drainage rates were higher when pleural abrasion was performed.

CONCLUSIONS

In addition to resulting in the same pneumothorax recurrence rate, thoracoscopic pleural abrasion with or without minocycline pleurodesis is safer than apical pleurectomy in the treatment of PSP. However, minocycline pleurodesis with or without pleural abrasion is not any more effective than pleural abrasion alone. Moreover, additional mechanical abrasion is not safer than additional staple line coverage with absorbable cellulose mesh and fibrin glue after thoracoscopic bullectomy because of increased postoperative pain. Additionally, pleural abrasion after thoracoscopic wedge resection should not be recommended for routine application due to the greater incidence of adverse effects than wedge resection alone. However, further large-scale, well-designed RCTs are needed to confirm the best procedure.

Risk factors for postoperative recurrence of spontaneous pneumothorax treated by video-assisted thoracoscopic surgery†

OBJECTIVES

Over the past two decades, video-assisted thoracoscopic blebectomy and pleurodesis have been used as a safe and reliable option for treatment of spontaneous pneumothorax. The aim of this study is to evaluate the long-term outcome of video-assisted thoracoscopic surgery (VATS) treatment of spontaneous pneumothorax in young patients, and to identify risk factors for postoperative recurrence.

METHODS

We retrospectively analysed the outcome of VATS treatment of spontaneous pneumothorax in our institution in 150 consecutive young patients (age ≤ 40 years) in the years 1997-2010. Treatment consisted of stapling blebectomy and partial parietal pleurectomy. After excluding 16 patients lost to follow-up, in 134 cases [110 men, 24 women; mean age, 25 ± 7 standard deviation years; median follow-up, 79 months (range: 36-187 months)], we evaluated postoperative complications, focusing on pneumothorax recurrence, thoracic dysaesthesia and chronic chest pain. Risk factors for postoperative pneumothorax recurrence were analysed by logistic regression.

RESULTS

Of 134 treated patients, 3 (2.2%) required early reoperation (2 for bleeding; 1 for persistent air leaks). Postoperative (90-day) mortality was nil. Ipsilateral pneumothorax recurred in 8 cases (6.0%) [median time of recurrence, 43 months (range: 1-71 months)]. At univariate analysis, the recurrence rate was significantly higher in women (4/24) than in men (4/110; P = 0.026) and in patients with >7-day postoperative air leaks (P = 0.021). Multivariate analysis confirmed that pneumothorax recurrence correlated independently with prolonged air leaks (P = 0.037) and with female gender (P = 0.045). Chronic chest wall dysaesthesia was reported by 13 patients (9.7%). In 3 patients, (2.2%) chronic thoracic pain (analogical score >4) was recorded, but only 1 patient required analgesics more than once a month.

CONCLUSIONS

VATS blebectomy and parietal pleurectomy is a safe procedure for treatment of spontaneous pneumothorax in young patients, with a 6% long-term recurrence rate in our experience. Postoperative recurrence significantly correlates with female gender and with prolonged air leakage after surgery.

Mechanical pleurodesis does not reduce recurrence of spontaneous pneumothorax: a randomized trial

BACKGROUND

Mechanical pleurodesis is widely used to treat primary spontaneous pneumothorax to decrease postoperative recurrence after thoracoscopic bullectomy, but it is unclear whether it actually reduces primary spontaneous pneumothorax recurrence. We aimed to investigate the effectiveness of mechanical pleurodesis after thoracoscopic treatment of primary spontaneous pneumothorax.

METHODS

In our parallel-group, prospective, randomized, controlled trail at 2 hospitals in China, 289 patients were enrolled from January 2010 to January 2013. Patients were randomly assigned (1:1) to receive thoracoscopic wedge resection only (WR group) or thoracoscopic wedge resection and mechanical pleurodesis (WR+MP group). This trial is registered with ClinicalTrial.gov (NCT01463553).

RESULTS

Intraoperative bleeding and postoperative pleural drainage were significantly lower in the thoracoscopic WR only group. Postoperative recurrence rate did not significantly differ between groups (log-rank test p=0.791; Breslow test p=0.722). In the thoracoscopic WR only group, no recurrences were found when bullae were isolated or limited; recurrence was 7.5% with the presence of multiple bullae. Younger patients had an increased risk of recurrence (relative risk 3.015; 95% confidence interval 1.092 to 8.324).

CONCLUSIONS

Thoracoscopic mechanical pleurodesis did not significantly decrease primary spontaneous pneumothorax recurrence compared with simple wedge resection, but intraoperative bleeding and postoperative pleural drainage rates were higher. Younger age increases the risk of recurrence.

VATS bullectomy and apical pleurectomy for spontaneous pneumothorax in a young patient with Swyer-James-Mc Leod syndrome: case report presentation and literature review focusing on surgically treated cases

BACKGROUND

Swyer-James-McLeod Syndrome (SJMS) is an uncommon, emphysematous disease characterized by radiologic hyperlucency of pulmonary parenchyma due to loss of the pulmonary vascular structure and to alveolar overdistension.

CASE REPORT

We herein describe a 15-year-old Caucasian patient with well-established SJMS since childhood who presented with spontaneous pneumothorax. Video-assisted thoracoscopic bullectomy with apical pleurectomy was performed. Since SJMS is considered an on-going inflammatory process, the patient one year after surgery exhibits excellent quality of life with no pneumothorax recurrence.

Risk factors predisposing to prolonged air leak after video-assisted thoracoscopic surgery for spontaneous pneumothorax

BACKGROUND

The goal of this prospective study was to determine risk factors for prolonged air leak (PAL) for patients who underwent video-assisted thoracoscopic surgery (VATS) for spontaneous pneumothorax.

METHODS

Between January 2002 and June 2012, a total of 2,292 patients were eligible for enrollment in the study: 1,800 patients had primary spontaneous pneumothorax and 492 patients had secondary spontaneous pneumothorax. There were 312 female and 1,980 male patients with a mean age of 41 years (range, 13 to 85 years). Twenty-three variables were recorded for each patient. The primary endpoint was rate of postoperative PAL (chest tube drainage for >7 days). Statistical evaluation used univariate and multivariate logistic regression analyses.

RESULTS

A total of 223 (9.73%) cases of postoperative PAL occurred in 2,292 patients. Comparing clinical characteristics between the patients with and without PAL, mean age in the air leak group (59 ± 18 y) was significantly older than that in non-air-leak group (39 ± 18 y) (p < 0.05). Multivariate analyses found 4 variables related to PAL (p < 0.05): age, American Society of Anesthesiologists scores, bilateral procedures, and bullae diameter. No significant relationships were found between pleural abrasions and/or talc pleurodesis and PAL.

CONCLUSIONS

Prolonged air leak is one of the most common complications after spontaneous pneumothorax operations. Age, American Society of Anesthesiologists scores, bilateral procedures, and bullae diameter were risk factors for PAL. Use of talc pleurodesis with pleural abrasion may not decrease the incidence of PAL in VATS spontaneous pneumothorax operation. Talc pleurodesis with pleural abrasion should be used cautiously in patients with significant comorbid conditions or advanced age.

Video-assisted thoracoscopic surgery for primary spontaneous pneumothorax in children

PURPOSE

There is controversy regarding the best way to prevent recurrences of primary spontaneous pneumothorax (PSP) in children. The purpose of this study was to evaluate the efficacy of video-assisted thoracoscopic surgery (VATS) for pediatric PSP.

METHODS

We retrospectively reviewed patients under 29 years of age who underwent VATS for PSP between March 2005 and February 2011. Patients were divided into 2 groups: children (under the age of 17 years) and young adults (over the age of 18 years).

RESULTS

Two hundred eighty-one VATS procedures in 257 patients were included in this study. The mean follow-up was 47.1 ± 20.5 months. No mortality was observed. The mean duration of pleural drainage was 3.4 ± 2.2 days. The overall recurrence rate was 6.8 %. The operative outcomes did not differ significantly. However, the recurrence rate was significantly higher in the children's group than the young adult group (10.6 vs. 3.9 %, P = 0.032). Younger age and postoperative prolonged air leak had a significantly higher risk of postoperative recurrence.

CONCLUSIONS

VATS is a safe and effective procedure for PSP in children. However, the risk of recurrence is increased in children and it is related to the formation of new bullae.