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Eur J Cardiothorac Surg 2001;19:396-399
© 2001 Elsevier Science NL

Recurrences following videothoracoscopic treatment of primary spontaneous pneumothorax: the role of redo-videothoracoscopy

Giuseppe Cardilloa, Francesco Faccioloa, Mohamed Regala, Luigi Carbonea, Felicita Corzania, Alberto Riccib, Massimo Martellia

a Unit of Thoracic Surgery, Azienda Ospedaliera S.Camillo-Forlanini, Ospedale Carlo Forlanini, Rome, Italy
b C.U.B.E. (Universita' La Sapienza), Azienda Ospedaliera S.Camillo-Forlanini, Ospedale Carlo Forlanini, Rome, Italy

Received 10 October 2000; received in revised form 2 February 2001; accepted 6 February 2001.

Corresponding author. Divisione di Chirurgia Toracica, Ospedale ‘Carlo Forlanini’ Via Portuense 332, 00149 Rome, Italy. Tel.: +39-06-5518-0680; fax: +39-06-663-8734
e-mail: gcardillo{at}scamilloforlanini.rm.it


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 Appendix A. Conference...
 References
 
Objective: There is very little experience regarding recurrences following videothoracoscopic (VATS) treatment of primary spontaneous pneumothorax. We report our experience with 19 patients who underwent redo-VATS to evaluate the feasibility of such surgical approach. Methods: From July 1, 1992 to September 1, 2000, out of 2136 VATS procedures performed at our institution, 597 patients (27.94%) underwent VATS treatment of primary spontaneous pneumothorax with a recurrence rate of 3.85% (23 cases). Primary VATS treatment in these patients was: talc poudrage, three cases; subtotal pleurectomy, three cases; ligation of the bullae + subtotal pleurectomy, 12 cases; stapling of the bullae + subtotal pleurectomy, two cases; ligation of the bullae + talc poudrage, one case; stapling of the bullae + talc poudrage, one case. Treatment of the 23 recurrences included: 15 redo-VATS, four standard thoracotomy, three pleural drainage, one bed rest. Four additional redo-VATS were also performed in four patients operated on in different institutions. Redo-VATS showed residual bullae in nine cases and a minimal leaking area in one patient; in the remaining nine patients no lesion was found. Redo-VATS treatment was: stapling of the bullae + talc poudrage in nine patients; suture of the leaking area with a no-knife stapler + talc poudrage in one patient; isolated talc poudrage in the remaining nine patients with no-evidence of bullae or blebs. Results: No mortality was reported; no major complications occurred. The conversion rate in the group of redo-VATS was 5.2% (one patient). At a mean follow-up of 32 months no patient showed recurrent pneumothorax. Conclusions: In the light of our initial experience, redo-VATS seems to be a promising tool for the surgical therapy of recurrences following VATS treatment of primary spontaneous pneumothorax.

Key Words: Videothoracoscopy • Pneumothorax


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 Appendix A. Conference...
 References
 
Most authors believe video-assisted thoracic surgery (VATS) to be the gold standard in the surgical management of recurrent spontaneous pneumothorax, even if some concern still exists [1–4].

As far as the number of VATS procedures in the treatment of primary spontaneous pneumothorax (PSP) is increasing, the issue of the surgical treatment of recurrences following VATS becomes a matter of debate. Up to now there is very little if any experience with the surgical management of such recurrences [5,6]. Many surgeons avoid VATS on a reoperated chest because of the presence of pleural symphisis. In the light of the large experience gained by VATS at our institution we have employed redo-VATS in the treatment of post-VATS recurrences.

In this paper we point out our experience to determine the feasibility and the results of 19 redo-VATS performed in a group of 27 patients treated because of recurrences following VATS treatment of PSP.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 Appendix A. Conference...
 References
 
From July 1 1992 to September 1 2000, of 2.136 VATS procedures performed at the Unit of Thoracic Surgery, Carlo Forlanini Hospital in Rome, 597 patients (27.9%) underwent VATS treatment of PSP. All procedures were performed with the patient under general anaesthesia and one lung ventilation.

The surgical protocol was tailored according to the Vanderschueren's classification [7] and to our previously published criteria [1]: stage I (no endoscopic abnormalities): isolated pleurodesis (talc poudrage or subtotal pleurectomy); stage II (pleuropulmonary adhesions): lysis of all adhesions and isolated pleurodesis (talc poudrage or subtotal pleurectomy); stage III (blebs/bullae <2 cm) and IV (bullae >2 cm): treatment of the bullae (stapling of the bullae or ligation of the bullae) and pleurodesis (talc poudrage or subtotal pleurectomy). Endoscopic parietal pleurectomy was performed according to Inderbitzi and colleagues [1]. Talc poudrage was accomplished by nebulization in the pleural cavity of 2 g of asbestos-free sterilized talc. The treatment of the bullae included ligation of the bullae with a 0 or 00 coated Vicryl Roeder loop (Endoloop EJ 10 G, Ethicon Inc., Somerville, NJ, USA) or minimal wedge resection with the endoscopic stapler (TSB 35, Ethicon Endo-Surgery, Cincinnati, OH, USA). Recurrent pneumothorax is defined as a pneumothorax greater than 10% of the hemithorax in size. At a mean follow-up of 49 months (range 1 to 97 months) recurrences were seen in 23 patients (3.8%). Recurrences occurred in 11 cases (47.8%) within 1 year from surgery. At 2 years from surgery, 91.3% of recurrences (21 cases) were present. As previously reported by us, the rate of recurrence is much higher following ligation of the bullae than stapling of the bullae (P<0.0001), and following parietal pleurectomy than talc poudrage (P<0.0001) [1]. For such reasons our treatment policy actually includes only talc poudrage as pleurodesis tool and only stapling of the bullae as method to treat the bullae. Recurrences were treated by redo-VATS in 15 patients (65.2%), standard thoracotomy in four patients (17.4%), chest drainage in three (13.0%) patients (with talc slurry in one case), and bed rest in one patient (4.4%) (Table 1). Four additional redo-VATS were performed in four patients previously operated on in different institutions and referred to our unit because of the evidence of recurrent pneumothorax. Before redo-surgery, all patients underwent CT scan of the chest to plan for the optimal entry sites for the ports.


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  		Table 1. Twenty-seven recurrences following VATS treatment of primary spontaneous pneumothorax

 
All redo-VATS were performed with the patient under general anaesthesia and one-lung ventilation. All procedures were performed by the senior surgeon (MM). The patient was placed in the lateral position with the arm held abducted to allow maximum superior displacement of the scapula and to open up the intercostal spaces. Old port sites were avoided. The first incision was placed according to the CT evidence of the recurrent pneumothorax. In all cases a 0-degree telescope (or operating scope) was used. Pleura was entered using a ‘tip and scope ’ technique: the scope is gently entered in the chest cavity dissecting adhesions by itself and by an endoscopic blunt tip dissector (endopath, Ethicon Endo-Surgery, Cincinnati, OH, USA). Once a clear space is created the subsequent port is introduced under direct thoracoscopic vision. Adhesiolysis is usually completed with three ports. The lung is inspected during gentle ventilation with saline in the pleural cavity to detect air leak. Residual bullae, when found, were treated by minimal wedge resection with the endoscopic stapler (TSB35/45). Leaking areas were treated either by minimal wedge resection either by no-knife stapling. (NSB 45, Ethicon Endo-Surgery, Cincinnati, OH, USA). In all cases a talc poudrage was also accomplished. At the end of the surgical procedure usually one drain (occasionally two) was placed through the existing incisions under endoscopic control with a blunt guide. If the water-seal test revealed a major air leak, the lung is routinely reinspected by the telescope.

All patients were entered in a follow-up program which included clinical interview and chest X-ray every 1, 3 and 6 months in the 1st year, and very 8 months from the 2nd to the 5th postoperative year. Follow-up ended October 1st, 2000.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 Appendix A. Conference...
 References
 
There were no postoperative deaths. No intraoperative complications were detected. No patient required blood transfusion. The conversion rate to open procedure in the group of 19 redo-VATS was 5.2% (one patient). Reason for conversion was the presence of extensive pleural adhesions with obliteration of the pleural cavity in a patient who previously underwent subtotal pleurectomy. It happened at the beginning of our experience. Adhesions were found in almost all patients; the rate of adhesions was higher following talc poudrage than pleurectomy. Intraoperative findings showed no parenchymal lesion in 10 patients (43.5%), residual bullae in 11 patients (47.8%), and leaking areas in two patients (8.7%).

In the 19 patients who underwent redo-VATS, the following treatment was used: stapling of the residual bullae plus talc poudrage in nine patients; suture of the leaking area with a no-knife stapler plus talc poudrage in one patient, isolated talc poudrage in nine patients with no evidence of residual bullae.

In the four patients who underwent standard thoracotomy, the treatment included stapling of the residual bullae plus total pleurectomy in three patients, and isolated total pleurectomy in one patient.

The overall postoperative complication rate was 7.7% (two of 26) and included one prolonged air leak (8 days) (following standard thoracotomy) and one localized pleural effusions (following redo-VATS) which resolved with thoracentesis (Table 1). The overall mean time for removal of chest tubes was 5.8 days: 5.7 days in the redo-VATS group (19 patients), 5.9 days in the standard thoracotomy group (four patients), 5.8 days in the drainage group (three patients).

At a mean follow-up of 33 months from redo-VATS, no recurrence was seen in the overall group.

One patient treated by bed rest experienced a minimal pleural detachment 6 months later which resolved spontaneously (Table 1).


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
Appendix A. Conference...
 References
 
The issue of the surgical treatment of recurrences following VATS treatment of spontaneous pneumothorax is becoming more and more important in the light of the increasing number of VATS and of the increasing evidence of recurrences following VATS treatment of spontaneous pneumothorax. Nowadays the overall recurrence rate associated with VATS treatment of spontaneous pneumothorax is around 4% in the world literature, which is very close to the 3.8% rate reported in the present series [1]. Recurrence rate is mainly related to the learning curve of the surgeon and to the type of the operation [1,8,9]. In a previous paper we stressed the safeguard and efficacy of our preferred approach, stapling of the bullae and talc poudrage by VATS, which has shown in a selected series of 195 patients an impressive 0.51% recurrence rate [1]. Actually there are no clear data available regarding the treatment of such recurrences: pleural drainage alone or associated with chemical pleurodesis (e.g. talc slurry), standard thoracotomy, axillary thoracotomy, redo-VATS. We believe that when a VATS procedure fails, there is the need to reinspect the lung and look for the reason of failure. A blind chemical pleurodesis through a pleural drainage is usually associated with loculated effusions and should not be allowed in young people in the 3rd millennium era. The reasons for non-operative approach in our series were refusal of surgery (two patients) and late referral to our institution (two patients drained elsewhere). The rationale for choosing VATS as the primary surgical approach for PSP, should lead the surgeon to try a redo-VATS instead of opening the chest. The reasons for choosing a thoracotomy instead of a redo-VATS approach in four patients of our series, were patient's choice (one case), paramediastinal pneumothorax with extensive obliteration of the cavity (one case), and beginning of our experience (two cases). Many authors ‘historically’ believe a previous operation to be a contraindication for a VATS procedure because of the presence of pleural symphisis which can lead to bleeding and damaging of the lung. Nevertheless it is generally known that adhesions are more dense after thoracotomy than after VATS, redo-VATS it is usually denied by most of the surgeons. Such attitude is not justified. In most cases VATS itself is associated with a minimal evidence of adhesions. As regards the treatment of pneumothorax, adhesions are much more related to the type of the pleurodesis which has been performed (pleural abrasion, pleurectomy, or talc poudrage) than to the treatment of the bullae (stapling or ligation). In the light of our experience adhesions were much higher following talc poudrage than following pleurectomy or pleural abrasions. Because of our surgical attitude of doing extensive pleurodesis in all patients, redo-VATS was highly demanding in our experience.

When recurrence occurs, the space in the pleural cavity must be carefully evaluated with CT scan which, in our opinion, helps the surgeon in choosing the entry sites for ports. With such approach we were able to re-entry in the pleural cavity whenever was the type of pleurodesis(talc poudrage, pleural abrasion, or subtotal pleurectomy). Some authors routinely create a pneumothorax by injecting 300 ml of air into the pleural cavity, than take a radiograph to plan for the optimal entry sites [10]. Yim, in a recently published paper did not find CT to be helpful in this approach. He advocated the use of the ‘clamp and finger’ technique [6]. In the light of our large experience, we preferred the original ‘tip and scope’ technique which requires great care in the adhesiolysis. Adhesiolysis was much more demanding following talc poudrage or subtotal pleurectomy than following pleural abrasion. Great care must be paid to the details of adhesiolysis to avoid bleeding and damage of the lung. If the lung is injured we recommend the use of fibrin sealant (Tissucol, Immuno-Baxter, Milano) or synthetic absorbable sealant (Advaseal, Ethicon Inc., Somerville, NJ, USA) to avoid postoperative air leak. The 0% complication rate and the very low conversion rate (one patient out of 19) with no further recurrence achieved in our experience seem to stress the feasibility of redo-VATS. Such procedure requires a very great experience with VATS and should be performed only in very selected referring institutions.

In conclusion, in the light of our initial experience, redo-VATS seems to be a promising tool in the treatment of recurrences following VATS treatment of PSP. Up to now there are no data in the world literature to support our thesis, anyway this study either in the light of the appealing long-term results presented either in the light of the wide reported experience, seems to be at least a message to other thoracic surgeons to test redo-VATS in the treatment of recurrences following VATS treatment of spontaneous pneumothorax.


   Acknowledgments
 
We thank our thoracic speciality nurses Antonio Vinci, Riccardo Ciampa and Domenico Tittone for their support, and Patrizia Gallo for her secretarial help.


   Footnotes
 
Presented at the 14th Annual Meeting of the European Association for Cardio-thoracic Surgery, Frankfurt, Germany, October 7–11, 2000.


   Appendix A. Conference discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 Appendix A. Conference...
References
 
Dr E. Stoelben (Freiburg, Germany): Six hundred VATS in that time is a big experience. Why did you change from pleurectomy to pleurodesis with talcum poudrage in this time?

Dr Cardillo: In a previous paper published in the February 2000 issue of the Annals of Thoracic Surgery we have presented a comparison study between talc poudrage and subtotal pleurectomy and between ligation of the bullae and stapling of the bullae, and we have shown a significant difference in favor of stapling of the bullae and talc poudrage. If we go through the analysis of the data I showed, most of the recurrences were seen in the patients with ligation of the bullae. Ligation of the bullae, as has been shown by Inderbitzi and colleagues (J Thorac Cardiovasc Surg, 1994;107:1410), is responsible for a high rate of recurrences.

Regarding the technique of pleurodesis, subtotal pleurectomy, which usually goes from the apex of the lung to the fifth or sixth rib, can be responsible for a percent of recurrences in the lower part of the lung, and that is what we have shown in our result. We have not evaluated pleural abrasion because in our experience we did not perform such a technique of pleurodesis.

Dr C. Piwkowski (Poznan, Poland): I would like to ask you about a group of patients in which during the procedure you could not find any air leak and any blebs. In our experience, which is not so big like yours, we find that in this group of patients, whether you just do pleurodesis or chemical or mechanical, it doesnt matter; the number of recurrences is higher than in the other group, and now we just always perform wedge resection of the apex of the lung in this group, even if we don't find any blebs, and in the histological examination we find some inflammatory fibrosis and some small blebs which could be this source, and I would like to ask you your opinion about this attitude.

Dr Cardillo: Regarding the need for a blind wedge resection of the apex of the lung, some authors, like Keith Naunheim from St. Louis (J Thorac Cardiovasc Surg, 1995;109:1198), have shown good results with such approach. In our opinion, and we believe that 597 primary spontaneous pneumothorax is a very good number, we do not agree with him. Some pathologists have found in the apex with no bullae a change called ELC, that means emphysema-like changes, and I think that you are talking about these changes. Regarding the problem of a blind apical resection of the lung, we are not in agreement with this approach. Anyway in patients with no evidence of disease, we are afraid of a higher rate of recurrences.

Dr. S Nazari (Pavia, Italy): I would like to ask you if you can give us some data on the bilateral incidence of apical pathology in your large series and eventually the incidence of pneumothorax sequentially in the same patient in your series.

Dr Cardillo: The incidence of sequential pneumothorax was not so high in our patients. The evidence of radiological bilateral bullous disease does not need a bilateral surgery. We treat pneumothorax only if there is a space, there is a pneumothorax, not because of radiological or CT scan evidence of bullous disease.

Dr J. Thorpe (Leeds, UK): Do you use the old port sites or do you use new port sites?

Dr Cardillo: In the beginning we tried to use the old port sites, but now, if possible, we avoid it because adhesions are more tough in the old entry site. Anyway, with pre-operative CT scan we can decide where we can enter.

Dr R. Stanbridge (London, UK): You say that redo-VATS is demanding. Have you had the possibility of considering insertion of a catheter with CT control into the air space and then insertion of tetracycline into the area rather than a redo-VATS procedure?

Dr Cardillo: It depends on the extension of the pneumothorax. When we say that redo-VATS is a demanding technique, it's because of the experience of the surgeons. I think that now the first choice in patients with a recurrent pneumothorax greater than 10% in size should be redo-VATS.

Dr V.V. Sokolov (Kiev, Ukraine): We prefer in primary pneumothorax to perform CT scans prior to thoracoscopy because it really helps to identify subpleural bullae and guide us in thoracoscopy that may eliminate the need for blunt resection of the apex. Do you do CT scans prior to thoracoscopy?

Dr Cardillo: CT scan is a good help in redo. Regarding the first surgery, I would ask you if you have compared how many negative CT scans are found in patients with small bullae. I believe that CT scan does not help you very much in the first surgery of pneumothorax. The bullae that you can see on CT scan, even with the high-resolution CT scan, are less than you can see with the scope. The magnification of the scope is around 16 or 20 and you are able to see even a small bleb that you cannot see at all with CT scan.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 Appendix A. Conference...
 References
 

  1. Cardillo G., Facciolo F., Giunti R., Gasparri R., Lopergolo M., Orsetti R., Martelli M. Videothoracoscopic treatment of primary spontaneous pneumothorax: a 6-year experience. Ann Thorac Surg 2000;69:357-361.[Abstract/Free Full Text]
  2. Jimenez-Merchan R., Garcia-Diaz F., Arenas-Linares C., Giron-Arjona J.C., Congregado-Loscertales M., Loscertales J. Comparative retrospective study of surgical treatment of spontaneous pneumothorax. Thoracotomy vs. thoracoscopy. J Surg Endosc 1997;11:919-922.
  3. Hatz R.A., Kaps M.F., Meimarakis G., Loehe F., Müller C., Fürst H. Long-term results after video-assisted thoracoscopic surgery for first-time and recurrent spontaneous pneumothorax. Ann Thorac Surg 2000;70:253-257.[Abstract/Free Full Text]
  4. Lang-Lazdunski L., de Kerangal X., Pons F., Jancovici R. Primary spontaneous pneumothorax: one-stage treatment by bilateral videothoracoscopy. Ann Thorac Surg 2000;70:412-417.[Abstract/Free Full Text]
  5. Yim A.P., Liu H.P. Complications and failures of video-assisted thoracic surgery: experience from two centers in Asia. Ann Thorac Surg 1996;61:538-541.[Abstract/Free Full Text]
  6. Yim A.P., Liu H.P., Hazelrigg S.R., Izzat M.B., Fung A.L., Boley T.M., Magee M.J. Thoracoscopic operations on reoperated chests. Ann Thorac Surg 1998;65(2):328-330.[Abstract/Free Full Text]
  7. Vanderschueren R.G.J.R.A. Le talcage pleural dans le pneumothorax spontane. Poumon-Coeur 1981;37:273-276.
  8. Schramel F.M.N.H., Postmus P.E., Vanderschueren R.G.J.R.A. Current aspects of spontaneous pneumothorax. Eur Respir J 1997;10:1372-1379.[Abstract]
  9. Massard G., Thomas P., Wihlm J.M. Minimally invasive management for fist and recurrent pneumothorax. Ann Thorac Surg 1998;66:592-599.[Abstract/Free Full Text]
  10. Viallat J.R., Rey F., Astoul P., Boutin C. Thoracoscopic talc poudrage pleurodesis for malignant effusions. A review of 360 cases. Chest 1996;110(6):1387-1393.[Abstract/Free Full Text]




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