Video-assisted thoracoscopic surgery for primary spontaneous pneumothorax

Negative Outcomes following Video-Assisted Thoracic Surgery

The author reviewed his personal experience with 776 video-assisted thoracoscopic procedures on 526 patients over a 34-month period, with particular attention to perioperative complications and procedure failures. There was one death (mortality rate 0.2%). Nonfatal complications comprised persistent air leaks (13), bleeding (4), wound infection (2), intercostal neuralgia (5), cerebrovascular accident (1), reexpansion pulmonary edema (1), deep vein thrombosis (1), prolonged ventilatory support (1), and port site recurrence (1), giving rise to an overall nonfatal complication rate of 5.5%. Procedure failures consisted of 4 incidences of recurrence of pneumothorax (out of 213 cases or 1.9%); 2 recurrences of malignant pleural effusion (out of 39 cases or 5.1%); 2 recurrences following resections for stage I lung cancer (out of 32 cases or 6.3%). Proportionally more complications and procedure failures were seen in the first 17 months compared to the following 17 months, in spite of the fact that more technically advanced procedures were performed in the latter period. Careful patient selection and attention to details are essential in optimizing surgical results.

Pediatric spontaneous pneumothorax

Spontaneous pneumothorax (SP) occurs when air enters the pleural space in the absence of a traumatic or iatrogenic etiology and is an uncommon phenomenon in the pediatric population. Although the typical presentation has been well described in the literature, much debate still surrounds the epidemiology, pathophysiology, diagnosis, and management of this condition in the pediatric population. To date, much of the emphasis in the pediatric literature has been on surgical options. Questions still remain regarding the true incidence of this disease in children, appropriate diagnostic imaging, and treatment recommendations for practitioners in the emergency department setting. This review of the evidence seeks to elaborate on current knowledge and clinical practice, as well as the applicability of adult recommendations to the pediatric population.

Management of spontaneous pneumothorax

Management of patients with a spontaneous pneumothorax continues to challenge clinicians. Recent guidelines help provide care pathways for these patients and highlight the many areas in need of additional study. Management options for spontaneous pneumothoraces should be selected based primarily upon a patient's clinical status. Observation or pleural air drainage, in selected patients, plays a significant role in patients with primary spontaneous pneumothorax. By contrast, pleural air drainage plays the central role in patients with a secondary spontaneous pneumothorax. Surgically directed recurrence prevention and air leak management are preferred for both primary and secondary spontaneous pneumothorax patients.

Thoracoscopy in the management of pneumothorax

Spontaneous pneumothorax is a common condition that impacts significantly on healthcare expenditure. However, optimal management of spontaneous pneumothorax remains a subject of considerable controversy. A thoracic surgeon's perspective on the use of thoracoscopy and video-assisted thoracic surgery with a focus on surgical techniques in the current management of this condition is presented.

Surgical aspects of chronic post-thoracotomy pain

Chronic post-thoracotomy pain is a continuous dysaesthetic burning and aching in the general area of the incision that persists at least 2 months after thoracotomy. It occurs in approximately 50% of patients after thoracotomy and is usually mild or moderate. However, in 5% the pain is severe and disabling. No one technique of thoracotomy has been shown to reduce the incidence of chronic postthoracotomy pain. The most likely cause is intercostal nerve damage, although the precise mechanism for this is not known. Future work needs to examine surgical technique in detail. Until then, patients need to be adequately warned of this sequela of thoracotomy.

Detection and localization of pulmonary air leaks using laser-polarized (3)He MRI

Pulmonary air leaks were created in the lungs of Yorkshire pigs. Dynamic, 3D MRI of laser-polarized (3)He gas was then performed using a gradient-echo pulse sequence. Coronal magnitude images of the helium distribution were acquired during gas inhalation with a voxel resolution of approximately 1.2 x 2.5 x 8 mm, and a time resolution of 5 sec. In each animal, the ventilation images reveal focal high-signal intensity within the pleural cavity at the site of the air leaks. In addition, a wedge-shaped region of increased parenchymal signal intensity was observed adjacent to the site of the air leak in one animal. (3)He MRI may prove helpful in the management of patients with pulmonary air leaks.

The results of thoracoscopic surgery for primary spontaneous pneumothorax

OBJECTIVE

To review our experience of video-assisted thoracoscopic surgery for the treatment of primary spontaneous pneumothorax.

DESIGN

Longitudinal cohort study following up consecutive patients for 3 to 4.3 years.

SETTING

Thoracic Surgery Department, Chest Diseases Hospital, Kuwait.

PATIENTS AND INTERVENTION

Seventy-two consecutive patients undergoing thoracoscopy for primary spontaneous pneumothorax from January 1994 to June 1996.

RESULTS

The mean age of the patients was 25 years (range, 15 to 40 years), and 67 were men (93%). All patients were successfully treated using video-assisted thoracoscopic technique. Recurrent pneumothorax was the most frequent indication for surgery, occurring in 49 patients. The most common method of management was stapling of an identified bleb, which was done in 56 cases. Pleurodesis was achieved by gauze abrasion (n = 39) and apical pleurectomy (n = 33). Postoperative prolonged air leak occurred in five patients (6.9%). There were no deaths attributable to the procedure. The mean (+/-SD) postoperative hospital stay was 4 +/- 2 days. Mean follow-up is 42 months (range, 36 to 54 months) for all patients. Pneumothorax recurred in four patients (5.5%) in whom pleural abrasion was done. The recurrences occurred in the first year of follow-up, three required a reoperation, and one healed by rest without pleural drainage.

CONCLUSIONS

Video-assisted thoracoscopic surgery is a safe procedure in the treatment of primary spontaneous pneumothorax. Apical pleurectomy is a more effective way of producing pleural symphysis. Long-term follow-up did not increase the rate of recurrence.

Video assisted thoracic surgery for spontaneous pneumothorax

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Video assisted thoracoscopic staple resection of a giant bulla

Video assisted thoracoscopic surgery (VATS) for spontaneous pneumothorax has been well described. However, there are few reports on the use of this technique on giant bullae. We report a 49 year old man with a symptomatic giant bulla who underwent a successful thoracoscopic staple resection. His chest drains were removed on the second postoperative day and he was discharged on the third postoperative day with virtually no discomfort. We conclude that thoracoscopic staple resection of a giant bulla is feasible technically and is an attractive alternative to the conventional open technique.

Immediate and long-term results after surgical treatment of primary spontaneous pneumothorax by VATS

BACKGROUND

Video-assisted thoracic surgery has recently evolved as a viable alternative to thoracotomy for spontaneous pneumothorax.

METHODS

A series of 163 patients with primary spontaneous pneumothorax were treated by video-assisted thoracic surgery. Seventy patients were treated for a recurrent episode, 64 patients for a persistent primary spontaneous pneumothorax, 24 patients for a contralateral episode, and 5 patients for a bilateral primary spontaneous pneumothorax. Stapling of bullae with an Endo-GIA stapler (Auto-Suture, Elencourt, France) was performed in 90% of the cases and parietal pleural abrasion was performed in each case.

RESULTS

One revisional lateral limited thoracotomy was required for bleeding. Six patients had a prolonged air leak; 2 of them were reoperated on by lateral limited thoracotomy. Two patients have had an incomplete reexpansion of the lung and required a reoperation. The duration of hospitalization was 6.9 +/- 3 days. With a mean follow-up of 24.5 months, three recurrences requiring a reoperation occurred; 3 other patients had a partial recurrence and healed by rest without drainage. The mean time to return to the occupational activity of the patients was 42 +/- 34 days. These results were compared with those of a previous series of 87 patients operated on by lateral limited thoracotomy.

CONCLUSIONS

With the development of surgical technique and video equipment, video-assisted thoracic surgery will probably become the treatment of choice of primary spontaneous pneumothorax.

Video-assisted thoracoscopic resection of type I cystic adenomatoid malformation in a 3-month old girl

A 3-month Chinese girl with type I cystic adenomatoid malformation involving both lobes of her left lung was successfully operated upon using the video-assisted thoracoscopic surgical (VATS) approach. The conventional endoscopic stapling device was used for resection without complications.

Video-assisted thoracoscopic wedge resections of pulmonary metastatic osteosarcoma: should it be performed?

We studied the use of video-assisted thoracoscopic (VAT) surgery in the management of metastatic osteosarcoma. From September 1993 to March 1994, we performed a total of 11 VAT wedge resections of pulmonary metastatic osteosarcoma in seven patients (six males, one female, age 12 to 46 years). Three patients had bilateral procedures performed either under the same anaesthesia or in stages. One patient had two operations on the same side. The average number of nodules excised was three. Two patients subsequently required formal lobectomies when the metastatic tumours were either too big or too close to the hilum for safe wedge resections. There was one death on postoperative day 3 due to dysrhythmia. One patient died 5 months later from a progression of his underlying disease. Two patients remained disease free up to 8 and 12 months, respectively, from their first operations. The average postoperative chest drain duration was 1.4 +/- 0.7 days and hospital stay 2.3 +/- 1.1 days. The procedure was well tolerated and postoperative morbidity was minimal. We conclude that although VAT wedge resection of pulmonary metastatic osteosarcoma is feasible technically and is associated with a short hospital stay and minimal morbidity, this approach cannot be recommended when complete resection of all metastases is the goal as the technique relies heavily on computed tomographic scans to detect nodules. Recurrence of metastasis from 4 to 6 months in three of seven patients argues against VAT surgery being an adequate procedure. The high cost of the staplers, in addition, is a secondary consideration.

Video-assisted thoracoscopic suturing of apical bullae. An alternative to staple resection in the management of primary spontaneous pneumothorax

We prospectively studied thoracoscopic suturing of apical bullae in the management of primary spontaneous pneumothorax. From June 1993 to July 1994, we performed 29 such procedures in 27 patients. (All males ranging in age from 15 to 40.) Bullae less than 2 cm in diameter were imbricated (18), while larger bullae were resected and repaired with 3/0 polypropylene suture (11). Postoperative morbidity was minimal. Averaged postoperative parenteral narcotic (Pethidine) requirement was 88 mg, chest drainage was 1.7 (range 1-4) days, and hospital stay was 2.5 (range 1-7) days. There was no recurrence after a mean follow-up of 10 months. In comparison, 32 patients prior to this study period underwent staple resection of apical bulla. Demographic data in the two groups were similar. Averaged Pethidine requirement in the "staple" group was 98 mg, chest drainage was 1.8 (range 1-5) days, and hospital stay was 2.6 (range 1-7) days. There was no statistical difference in the two groups with respect to pain medication, chest drainage, or hospital stay. The technique of thoracoscopic suturing can be easily acquired. In view of the high cost of staple-cutters, endoscopic suturing should be considered as a viable alternative to staple resection of apical bullae in the treatment of primary spontaneous pneumothorax.

Video-assisted thoracoscopic surgery in the paediatric population

OBJECTIVE

Video-assisted thoracoscopic surgery (VATS) is now widely practised in adults but there are few publications on its application in the paediatric population.

METHODOLOGY

Retrospective review of the authors' experience with VATS in children under 16 years old during an 18 month period in a university teaching hospital.

RESULTS

From September 1993 to March 1994, VATS was attempted in 14 patients. Five were unsuccessful because of pleural symphysis or inability to collapse the upper lung. Ten cases of VATS were successfully performed in the remaining nine patients (eight males, one female; age range from 22 days to 15 years old). These included two drainages and limited decortications for loculated pleural effusion, one guided drainage of pericardial effusion, one thymectomy for thymic hyperplasia, three wedge resections for metastatic pulmonary osteosarcoma and three bleb excisions and pleurodesis for primary spontaneous pneumothoraces. There were no intra-operative complications. There was one death from dysrhythmia following an uneventful wedge resection. The mean duration of chest tube drainage was 1.4 days and postoperative hospital stay 2.6 days excluding two patients who stayed for further medical treatment.

CONCLUSION

VATS is a useful approach in selected cases but further development of this approach awaits refinement of anaesthetic technique and endoscopic instrumentation.

Video-assisted thoracoscopic lobectomy: a word of caution

Advances in video-assisted thoracoscopic (VAT) surgery allow it to assume an increasingly important therapeutic role. Two successful VAT lobectomies (left upper lobe and right lower lobe) were performed in patients with stage I adenocarcinoma. An 8 cm access minithoracotomy for hilar dissection and subsequent specimen delivery was used. Routine mediastinal node sampling was performed thoracoscopically as would be done conventionally. Video-assisted thoracoscopic lobectomy of the right upper lobe was attempted in another patient but he required emergency conversion to open thoracotomy because of bleeding from mechanical failure of the vascular staple-cutter. Although VAT lobectomy is feasible technically, attention to detail is important when mechanical devices are used to minimize the chance of malfunctioning. Once disaster occurs the surgeon should be capable of dealing with the consequences.

Primary spontaneous pneumothorax treated by video assisted thoracoscopic surgery--results of intermediate follow up

BACKGROUND

Primary spontaneous pneumothorax (PSP) is a common clinical condition associated with high recurrence if no definitive treatment is given and could be life threatening if left untreated. The best treatment for this condition, however, remains controversial.

AIMS

A prospective study of patients with PSP treated by video assisted thoracoscopic surgery (VATS) after a mean follow up of 16 months.

METHODS

Between September 1992 and April 1994, 114 VATS procedures were performed on 110 patients with PSP (including four patients with bilateral presentation) by one surgical team from a single institution. Mechanical pleurodesis with Marlex mesh was performed on all patients. In addition, apical bullae were identified in 100 cases (88%) and these were resected.

RESULTS

There was no mortality. The median hospital stay was three days. The procedure was well accepted by patients and this was reflected subjectively in a visual analogue scale and objectively in the requirement of postoperative analgesia. Complications included one wound infection, one bleeding, eight persistent air leaks over ten days. We had two failures with recurrence of pneumothorax occurring one week and two months postoperatively (mean follow up of 16 months). Late morbidity with intercostal neuropathy was identified in nine patients but only two of them required oral analgesics.

CONCLUSION

VATS is a quick and effective treatment for PSP. We currently recommend VATS for patients with recurrent spontaneous pneumothorax, as well as first time pneumothoraces associated with tension, bilaterality, frequent travelling, unreliable follow up and persistent air leak over three days.

One hundred consecutive cases of video-assisted thoracoscopic surgery for primary spontaneous pneumothorax

We reviewed our experience on video-assisted thoracoscopic surgery (VATS) from our first 100 cases of primary spontaneous pneumothorax (PSP) performed at our institution from September 1992 to January 1994. Apical bullae were identified in 87% of cases. Mechanical pleurodesis with Marlex mesh was performed on all patients. Excision with endoscopic staple cutter was performed in 69 cases; an endoloop was used in five cases; ablation with an argon beam coagulator (ABC) was done in six cases; excision with endoscopic suturing occurred in seven cases; and mechanical pleurodesis alone was used in 13 cases. The overall median postoperative chest tube duration was 2 days (range 1-25 days) and hospital stay 4 days (range 1-30 days). Complications occurred in 8 cases (8%): 1 wound infection; 1 chest wall bleeding; and 6 persistent air leaks which lasted for more than 10 days (one of which eventually required an axillary thoracotomy for control). Procedure failure with recurrence occurred in three cases (3%) at a mean follow-up of 17 months (range 8-24 months). The ABC group alone was responsible for one recurrence and two persistent leaks. We conclude that with the VATS approach in the treatment of PSP, staple resection of apical bullae is quick and most reliable but costly. Endoloop and hand suturing are applicable to selected patients with small and localized bullae and should be further studied, while our limited experience does not favor ABC as the primary treatment modality.