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Eur J Cardiothorac Surg 2001;20:897-898
© 2001 Elsevier Science NL

Letter to the Editor

Primary spontaneous pneumothorax. Is video-assisted thoracoscopy stapler resection with pleural abrasion the gold-standard?

Department of Thoracic Surgery, University of Torino, San Giovanni Battista Hospital, v. Genova 3-10126, Turin, Italy

Received 14 March 2001; received in revised form 20 June 2001; accepted 28 June 2001.

Corresponding author. Tel.: +39-011-633-6635; fax: +39-011-696-0170
e-mail: ottavio.rena{at}tiscalinet.it

Key Words: Spontaneous pneumothorax • Video-assisted thoracoscopic surgery • Stapler lung resection • Pleural abrasion • Pleurodesis

Spontaneous pneumothorax is a common disorder with an incidence of between four and nine cases per 100,000 per year. Tube thoracostomy is the usual initial treatment and has been successful in most patients. The greater liability of pneumothorax to recur constitutes a special problem since the chances of a further recurrence increase with the number of episodes. The effective way to resolve the pneumothorax and prevent recurrences is surgical excision of the pathological lesion related to its onset (blebs or bullae) associated with pleural surface fusion.

We submitted 133 patients, 113 males and 20 females (median age 26, range 12–37 years) to video-assisted thoracoscopic surgery (VATS) procedures for primary spontaneous pneumothorax. Nineteen were operated on for persistent air-leak after first episode, 114 for recurrent pneumothorax; four patients were operated on for contralateral episode after the first intervention. In 107 operations out of 137 (78%), blebs or bullae were identified and submitted to stapler resection; every patient underwent pleural abrasion.

Persistent air-leak for more than 7 days (median 9, range 7–12) in six (4.3%) and bleeding in three out of 137 (2.2%) operations were encountered. Two patients out of six were submitted to revision minithoracotomy because of a copious air-leak: not previously identified leaking lesion was demonstrated and sutured. Other four cases were managed by thoracic tube only. One patient out of three with postoperative bleeding was submitted to thoracotomy and bleeding was controlled by clipping a small branch of an intercostal artery. The median chest tube duration was 2 days (range 2–11) and median hospital stay was 3 (range 3–12) days. No perioperative death occurred. During a median follow-up of 53 (range 6–96) months, six episodes of recurrent pneumothorax after stapler resection (3.6%) were encountered. One out of five was of minimal entity and did not require any management; the other four were submitted to re-do VATS, stapler resection of recurrent parenchimal blebs and pleural abrasion. Postoperative hospital stay was uneventful.

The international literature reports recurrence rates of pneumothorax ranging from 2.1 to 7.9% and from 0 to 4.5% for pleural abrasion and limited pleurectomy, respectively [1–3]. An interesting review of multi-institutional data for about 1365 patients refers recurrence rates of 0, 2.7, 4.4 and 7.9% when talc poudrage, parietal pleura coagulation, apical pleurectomy and pleural abrasion were compared [4]. Extensive pleurectomy and talc poudrage seem to be the only two procedures allowing complete control of pneumothorax recurrences [4,5]. Both procedures are related to significant postoperative pain, increased perioperative complication rate and impaired long-term pulmonary function.

Our results are similar to those published in the literature and a 3.6% recurrence rate is quite similar to those reported about apical pleurectomy by VATS. Using thoracoscopy with stapled wedge resection and pleural abrasion, we have demonstrated a short postoperative chest drain duration and hospital stay. We think that the goal in the surgical management of spontaneous pneumothorax is to secure the less recurrence rate with no mortality and quite null morbidity and functional impairment, even if transitory, in young health patients. After consideration of all the above-mentioned factors, we consider video-assisted thoracoscopy with stapler resection and pleural abrasion the gold standard in the management of spontaneous pneumothorax.

References

1. Ayed A.K., Al-Din H.J. The results of thoracoscopic surgery for primary spontaneous pneumothorax. Chest 2000;118:235-238.[Abstract/Free Full Text]
2. Chan P., Clarke P., Daniel F.J., Knight S.R., Seeranayagam S. Efficacy study of video-assisted thoracoscopic surgery pleurodesis for spontaneous pneumothorax. Ann Thorac Surg 2001;71:452-454.[Abstract/Free Full Text]
3. 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]
4. Leo F., Pastorino U., Goldstraw P. Pleurectomy in primary pneumothorax: is extensive pleurectomy necessary?. J Cardiovasc Surg 2000;41:633-636.[Medline]
5. Hurtgen M., Linder A., Friedel G., Toomes H. Video-assisted thoracoscopic pleurodesis. A survey conducted by the German Society of Thoracic Surgery. Thorac Cardiovasc Surg 1996;44:199-203.[Medline]

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Giuliano Maggi Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Casadio, C. Articles by Maggi, G. Search for Related Content PubMed PubMed Citation Articles by Casadio, C. Articles by Maggi, G. Related Collections Pleura