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Eur J Cardiothorac Surg 2001;20:42-45
© 2001 Elsevier Science NL
Thoracic Department, University of L'Aquila, Hospital of Teramo, Teramo, Italy
Received 21 November 2000; received in revised form 28 February 2001; accepted 13 March 2001.
Corresponding author. Via Ciaccio, 33, 64100 Teramo, Italy. Tel.: +39-0861-414798; fax: +39-0861-211626
e-mail: r.crisci{at}libero.it
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Abstract |
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 Top Abstract 1. Introduction2. Materials and methods3. Results4. DiscussionReferences |
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Key Words: Spontaneous pneumothorax • Video-assisted thoracic surgery
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1. Introduction |
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TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionReferences |
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The choice of treatment for this benign pathology is the cause of much debate among schools of surgery all the world over [1–4]. The advent of video-assisted thoracic surgery (VATS) has certainly had a determining role in modifying therapeutic treatment with this methodology being currently more in use in respect to open chest surgery, given its mini-invasive nature [4].
Today, most experts agree on the technique to be used with VATS (wedge resection and pleurectomy) which provides excellent results together with a very low percentage of relapse. In contrast, the choice of effecting a surgical procedure on first spontaneous pneumothorax without waiting for an eventual relapse is the cause of much animated discussion. Some authors are in favour of this solution and maintain that a benign pathology such as spontaneous pneumothorax must become a sure and definitive treatment [1,2]. Other authors challenge this, arguing that a minimal therapeutic treatment (pleural drainage) is adequate in most cases [5,6].
This study aims to contribute to the justification of the use of VATS on first spontaneous pneumothorax through the analysis of some parameters verified in two groups of patients treated, respectively, with pleural drainage and VATS.
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2. Materials and methods |
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TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionReferences |
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The patients were divided into two groups of 35 each, chosen homogeneously with regard to age and sex, considering both patients with primary and secondary spontaneous pneumothorax in both groups. Patients in the first group (33 primary spontaneous pnemothorax and two secondary, 21 males and 14 females with a mean age of 24 years) were treated with pleural drainage; patients in the second group (31 primary spontaneous pneumothorax and four secondary, 18 males and 17 female with a mean age of 27.7 years) underwent VATS.
The first group used Maalinkrofdt® drainages, sized between 24 and 32 Ch., according to the physical formation of the patients. These were introduced by thoracostomic access under local anaesthesia generally in the IV or V intercostal space on the mean axillary line and connected to continuous suction.
The patients of the second group underwent VATS under general anaesthesia with selected bronchial intubation using the classic ‘swordsman’ positioning on the operating table. All patients were fitted with three thoracostomic points of entry, one for the videocamera between the VI and VII intercostal spaces and two for the surgical instruments at level III or IV intercostal space on the anterior and posterior axillary line.
The surgical technique used was uniform in the patients where it was possible to identify bollous dystrophic zone, air leaks or blebs (80% of the patients). In these cases a complete wedge resection was effected with a so-called ‘leopard skin’ pleurectomy. In the cases in which it was not possible to identify pathological zones, an apical wedge resection was effected with a particularly large and accurate pleurectomy.
The average time of an intervention was 18 min (excluding time required for anaesthesia). At the end of the intervention one or two drainage tubes were inserted through an already existing thoracostomic entry point and the patient was connected to continuous suction.
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3. Results |
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TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionReferences |
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3.1. Prolonged air leaks
Leaks were considered prolonged air leaks when the leaks went beyond 6 days following surgical intervention; given complication was verified in four patients in the first group and two patients in the second group (Table 1).
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3.2. Time of pleural drainage
The average length of time for pleural drainage was 9 days for patients in the first group and 3.9 days in the second group (these data include the two patients from the first group as well as two from the second group with prolonged air leaks. It does not include the two patients from the first group who underwent VATS afterwards) (Table 1).
3.3. Hospital stay
The mean hospital stay for the first group (pleural drainage) was 12 days, compared to 6 days for patients in the second group (VATS) (Table 1).
3.4. Management costs
The average cost pro capite for the hospital stay is estimated at $220.00 on the basis of cost per day of bed plus costs of surgical intervention as well as materials used.
In the first group (pleural drainage) in which the average cost is $2,650.00, it is necessary to add an additional $50.00 for surgical materials, reaching a total of $2,700.00.
In the second group (VATS) where the average hospital stay was $1,325.00, the costs of the operating theatre and surgical materials must also be added.
Assuming usage of reusable surgical instruments, the expense is limited to that of disposable mechanical endoscopic staplers and potential reloads required as well as post-operative drainage tubes. This expense amounted to an average of $600.00 for a total of $1,925.00 for the second group (Table 2).
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In the second group, however, recurrence was limited to one case only, about 15 days after VATS and was treated with axillary mini-thoracotomy.
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4. Discussion |
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TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionReferences |
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In spite of the advent of VATS, some surgeons do not consider this method of treatment an ideal choice in dealing with this benign pathology, preferring to use other surgical approaches such as axillary mini-thoracotomy [4].
Most authors reject immediate treatment with videosurgery in cases of first spontaneous pneumothorax, opting instead for traditional pleural drainage and delaying intervention until recurrence [5].
In keeping with our findings, treatment of this pathology may be considered ‘suitable’ when responding to the following three requisites:
A salient fact is the notable difference between operating costs in the two groups (a difference above $825.00 per capite in favour of the second group) due largely to the decrease in the length of stay in hospital. This result, which we are not naturally the first to discover, and has been amply documented by other authors [1,7,8], but which is becoming more and more important in the financial management of public health resources.
Aside from these considerations, it is undeniable that VATS presupposes the administration of anaesthetic along with a surgical risk that does not weigh upon the patient when opting for treatment with pleural drainage. However, it must be said that the advanced state of technology in endoscopic instruments along with decades of experience by surgeons with this method, permits a rapid execution of the intervention and consequently reduced use of anaesthetic (an average of 30 min) with low doses of drugs which wear off quickly. All these elements together with the fact that intra and post-operatory complications are practically absent, reduce risk to the minimum.
Also if the insertion of pleural drainage, beyond the manoeuvres that can cause a high degree of stress and trauma in many patients, results to be a treatment still less invasive to VATS, this aspect comes amply compensated considering VATS is a very definitive treatment for this pathology.
Apart from the experience of the operator [9], much depends on the operatory technique executed during VATS.
In conformity with other findings [1,9], the most dependable technique in use today consists of the wedge resection in the identifiable dystrophic zones associated with a partial or sub-total pleurectomy. It is our custom to effect a pleurectomy defined as ‘leopard skin’ which includes in most interventions (or rather when dealing with dystrophic zones or blebs which can be identified at the level of the pulmonary apex) about 2/3 of the pleural cavity, starting from the apex and working downwards to its base. In cases where dystrophic zones supplied by other pulmonary segments are involved (apical segment of the lower lobe segments of the middle lobe for example), the pleurectomy must include areas below even the lower pleural cavity. In cases where no dystrophic parenchymal zones or air leaks are identifiable (20% in our findings), it is well to effect a wedge resection of the pulmonary apex (where the presence of even dystrophic alterations or blebs, even if microscopic, are statistically higher) with a broader and more accurate pleurectomy.
In these patients (20% – seven patients) histological examination of the apex of the lung showed a ‘micro-dystrophic’ zone in six cases and normal parenchyma in one case; these patients showed no air leaks following surgical intervention.
As it is difficult to object to what is clear evidence of low percentage of recurrence (one out of 35 patients studied) in favour of VATS, the main criticism levelled at this choice with regards to economic evaluation is the fact that patients who might never have presented a recurrence of pneumothorax in future may undergo a ‘useless’ operation [5].
In the final economic evaluation, if we take into consideration the ‘theoretic’ costs concerning the patients undergoing VATS, presumably not developing a second pneumothorax (referring to first group data: about 70% – 27 patients), we note that the cost can decrease from $69,515.00 to $17,540.00, saving theoretically about $52,000.00 (Tables 3 and 4).
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In reality we do not know how many patients who come to our attention with spontaneous pneumothorax may suffer a recurrence following pleural drainage alone; not even spiral CT is able to give us a certain correlation between the anatomical state of the lung and a potential recurrence.
At the moment we are treating a patient with pleural drainage and we are obliged to inform him of the possibility of a recurrence of the pathology (20–30% of cases in case studies) as well as that of another hospital stay complete with a surgical procedure.
Certainly, this information is of no psychological advantage to the patient who (particularly if young) leaves the hospital with concerns about returning, altering his lifestyle and his social life (renunciation to sports, for example) for fear of a recurrence.
Instead, patients who have undergone VATS are secure in the knowledge that the intervention is both definitive and resolutive, and can have a fast return to normal social life.
It may be said that beyond the cost-effectiveness of this procedure, this last ‘psycho-social’ motivation alone may prove to be a valid reason in favour of the treatment of first spontaneous pneumothorax by videothoracoscopy, therefore, in our opinion, it is not necessary to talk about ‘useless operation’ and ‘unnecessary costs’.
It is doubtless that this question will continue to be the source of many and broader case studies.
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Footnotes |
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References |
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TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionReferences |
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This article has been cited by other articles:
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  K. M. Ryu, P. W. Seo, S. Park, and J.-W. Ryu Complete atelectasis of the lung in patients with primary spontaneous pneumothorax. Ann. Thorac. Surg., March 1, 2009; 87(3): 875 - 879. [Abstract] [Full Text] [PDF]
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H. Kim, H. K. Kim, Y. H. Choi, and S. H. Lim Thoracoscopic bleb resection using two-lung ventilation anesthesia with low tidal volume for primary spontaneous pneumothorax. Ann. Thorac. Surg., March 1, 2009; 87(3): 880 - 885. [Abstract] [Full Text] [PDF]
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J.-S. Chen, H.-H. Hsu, K.-T. Tsai, A. Yuan, W.-J. Chen, and Y.-C. Lee Salvage for Unsuccessful Aspiration of Primary Pneumothorax: Thoracoscopic Surgery or Chest Tube Drainage? Ann. Thorac. Surg., June 1, 2008; 85(6): 1908 - 1913. [Abstract] [Full Text] [PDF]
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