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Fast-track video-assisted bullectomy and pleurectomy for pneumothorax: initial experience and description of technique

John Radcliffe Hospital, Headington, Oxford, UK

Received 14 September 2008; received in revised form 7 May 2009; accepted 19 May 2009.

^_* Corresponding author. Address: Department of Thoracic Surgery, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, UK. Tel.: +44 1865221121; fax: +44 1865220244. (Email: Edward.Black{at}orh.nhs.uk).

Objective: Pleurectomy ± bullectomy by video-assisted thoracoscopic surgery (VATS) is an established surgical procedure for pneumothorax. Early ambulation and discharge should be a reasonable goal. This study explores the feasibility of day-case surgery and identifies the obstacles requiring further work to facilitate day-case pneumothorax surgery. Methods: Between June 2007 and May 2008, 16 consecutive patients underwent video-assisted thoracoscopic surgery bullectomy ± pleurectomy (under the care of a single surgeon) with immediate connection to an ambulatory drainage system in the theatre following surgery. Analgesia comprised temporary paravertebral with early conversion to oral opiate ± paracetamol. There were 13 males (81%), average age 23 (range: 17–29) years, and three females (19%), average age 35 (range: 22–46) years. Twelve patients (75%) had left-sided disease, of which nine (56%) underwent elective surgery. All patients had previously suffered at least one primary spontaneous pneumothorax. Patients with probable secondary pneumothorax were excluded from the study. Length of stay (LOS) was compared with a control group of patients conventionally treated prior to the study. Results: In 13 patients (81%), early discharge was achieved 1 (range: 1–2 days) day post-op, whilst connected to an ambulatory drainage system. In three patients, early discharge was not achieved. One of these patients had the chest drain removed prematurely and remained an inpatient for 3 days with aspiration and observation for a small pneumothorax. The two remaining patients required extended inpatient admissions due to postoperative non-surgical complications. In the 13 patients discharged immediately, the time to drain removal (in clinic) was electively 7 days (range: 2–11 days). Two patients required re-admission: one for contralateral spontaneous pneumothorax and another for an ipsilateral basal pneumothorax treated with a drain. Conclusion: We have shown early discharge with ongoing ambulatory drainage following VATS pleurectomy ± bullectomy in patients with primary pneumothorax to be feasible with paravertebral in the theatre and rapid conversion to oral analgesia. Patients managed intercostal drains at home. Limiting factors such as postoperative nausea and pain control usually can be sufficiently managed in the outpatient. Shorter stays may have a beneficial financial result. Long-term follow-up and a quantification of the patients experience is warranted.

Key Words: VATS • Thoracoscopy • Pleurectomy • Bullectomy • Fast-track • Discharge