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Eur J Cardiothorac Surg 2006;29:6-8
© 2006 Elsevier Science NL

Thoracoscopic parietal pleural argon beam coagulation versus pleural abrasion in the treatment of primary spontaneous pneumothorax

^a Division of Thoracic Surgery, Department of Surgical Sciences, University of Parma, Viale Gramsci 14, 43100 Parma, Italy
^b Department of Public Health, University of Parma, Italy

Received 15 September 2005; received in revised form 21 October 2005; accepted 25 October 2005.

^_* Corresponding author. Tel.: +39 03406 874733; fax: +39 0521 992019. (Email: antonio.bobbio{at}unipr.it; antonboa{at}hotmail.com).

	Abstract

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

 
Objective: The obliteration of pleural space is useful to prevent recurrences of spontaneous pneumothorax. We retrospectively compared the results of pleural argon beam coagulation versus pleural abrasion in the treatment of primary spontaneous pneumothorax. Methods: Between 1996 and 2004, 136 patients underwent surgery for primary spontaneous pneumothorax, with 143 surgical procedures, all performed by VATS. Indications were recurrent pneumothorax in 107 patients, a complicated first episode in 29 and occupational activity in 7. Six patients were excluded because of postoperative histopathological diagnosis other than pulmonary emphysema. In 70 cases pleurodesis was performed with argon beam coagulation and in 67 by Marlex° mesh abrasion. These techniques were employed during two different periods. Median follow-up was 68 months in the Marlex° group and 41 in the argon group. The two groups resulted as being homogeneous for gender, age, smoking attitude and surgical indication. Statistical analysis was done with ² and Fisher's test. Results: No postoperative mortality was observed. Mean recovery time was 5 days. There were three patients with postoperative bleeding who underwent re-operation. There were nine cases of prolonged air-leak, one needing surgical exploration. Nine recurrences were noted, all requiring surgery. Two recurrences were observed in the group treated by pleural abrasion (3.4%) and seven in the group treated by argon coagulation (10.7%). The Fisher's test failed to demonstrate a statistical significance between the two procedures in terms of recurrence rate (p = 0.18). Multivariate analysis yielded no risk factors for recurrences. Postoperative complications resulted as being equally distributed in both groups. Conclusion: After primary spontaneous pneumothorax, pleurodesis induced by argon beam parietal pleural coagulation resulted as being no better than that obtained by pleural abrasion in the prevention of recurrences. No benefits in terms of postoperative complications resulted by use argon beam coagulation.

Key Words: Pneumothorax • Pleural abrasion • Argon beam coagulation

	1. Introduction

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

 
The principles of surgical therapy in the case of primary spontaneous pneumothorax (PSP) are the resection of the pulmonary blebs and the obliteration of the pleural cavity; since its introduction in 1990, video-assisted thoracic surgery (VATS) has become, for most thoracic surgeons, the preferred surgical approach for PSP treatment [1,2]. The VATS guided procedure to obtain the obliteration of the pleural cavity, however, is still widely varied in practice [3]; although good consensus has been achieved in considering parietal pleural abrasion the method of choice to induce pleurodesis, parietal pleurectomy, pleural talc poudrage, parietal pleural diathermy or laser coagulation are all still commonly used [4–7].

The argon beam coagulator (ABC), delivering a monopolar current to tissue via an ionised channel of argon gas has been proved to be an effective method for tissue electrocauterisation; it has been reported as safe and efficient in various thoracic procedures [8]. However, in the case of PSP it has been little used, and then mostly to destroy subpleural blebs [9,10]. No large series have been reported regarding its possible indication of inducing pleurodesis by the electrocoagulation of the parietal pleura. The potential benefits of this technique involve reducing the operative risk of bleeding or nerve injury deriving from mechanical scarification of the parietal pleura and preserving intact the extrapleural tissue layers.

The aim of the study was to investigate the efficacy of pleurodesis by ABC in the prevention of PSP recurrence compared to pleurodesis by pleural abrasion. Duration of hospital stay and outcome of surgery including complications and mortality were also documented to evaluate the surgical results of these procedures.

	2. Materials and methods

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

 
We retrospectively collected the clinical records of all patients who underwent surgery for PSP during the period between January 1996 and December 2004. Diagnosis of PSP was sustained in patients under 40 years old and when pneumothorax occurred in the absence of a known underlying pulmonary disease or recent traumatic event. Surgery was indicated at the first episode when the latter was complicated either by persistent air leak or by haemothorax, or when it was hypertensive or bilaterally simultaneous; also in the case of private or professional hazard, surgical treatment was offered at the first episode. Surgery was indicated in all cases of a second episode.

2.1 Surgical technique
All procedures were performed by VATS with three trocar sites. All patients had a selective bronchial tube positioning. A complete pleural exploration was done to search for pulmonary abnormality and for active pulmonary air leaks. When the offending bullae or blebs were identified, they were resected with an endostapler. In the case of diffuse disease and when there were no evident lung abnormalities, the lung apex was resected for histopathological characterisation.

Pleurodesis by pleural abrasion was performed with a Marlex° mesh held on a long curved sponge stick, by scarification of the thoracic wall parietal pleura except for the posterior aspect of the first rib. Pleurodesis by ABC was performed with an endoscopic electrosurgical device on the same pleural aspect: the generator was set between 40 and 80 W and the argon gas flow was fixed at 8 standard litres per minute (Force GSU, Valleylab, Tyco Healthcare Group LP, CO, USA). With both procedures, one drain was left in place connected to an underwater seal bottle with a negative pressure of 20 cm H₂O. In the case of persistent air leaks, the drain was left in place until 48 h after the air leaks had stopped. Without air leaks the drain was retrieved on the fifth postoperative day and, on the same day, discharge from hospital was permitted after a normal chest X-ray.

On final pathologic examination, those patients with a diagnosis other than pulmonary emphysematous dystrophy were excluded from the study (three cases of pleural endometriosis, two cases of histiocytosis and one case of lymphangiomyomatosis). Starting from January 1996, all patients enrolled were treated with pleural abrasion by VATS; in May 1999, ABC pleurodesis was introduced and since then has been preferred to pleuroabrasion. Follow-up was completed in January 2005 by telephone contact, and answers from 116 patients (89%) were collected. Statistical analysis was done by ² and Fisher's test.

	3. Results

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

 
The study included 130 patients, with 137 surgical procedures performed. Preoperative clinical data of the patients are shown in Table 1 . There were 67 procedures done with Marlex° mesh among 60 patients and 70 procedures on the same number of patients done with ABC. The two groups resulted as being homogeneous for age, sex, smoking attitude and surgical indication. The early and late results of surgical treatment are shown in Table 2 . No postoperative deaths were noted. Postoperative complications accounted for three cases of postoperative haemothorax (2.2%), all successfully re-operated on, and nine cases of prolonged air leaks (6.6%). Among these latter patients, one was re-operated on because of an associated collapsed lung, and two were discharged on the 12th postoperative day with the pleural drain connected to a Heimlich valve. Mean recovery time was the same for both groups. Long-term follow-up was completed for 123 procedures: 65 in the argon group, with a mean follow-up of 41 months (range 7–67), and 58 in the Marlex° group, with a mean follow-up of 76 months (range 1–106). Nine recurrences were observed in the whole study population: 2 (3.4%) in the group treated by pleuroabrasion at a mean interval time of 3 months (range 2–4), and 7 (10.8%) in patients treated by ABC at a mean free interval time of 10 months (range 1–36). Although the rate of recurrences with ABC was three-fold higher than after pleural abrasion, the Fisher's test failed to demonstrated a statistical significance (p = 0.18).

	4. Discussion

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

The principle of ABC used to induce pleurodesis is based on rawing the parietal pleural mesothelium by direct electrocoagulation delivered through a sprayed gas jet flame. Exploring the role of ABC in the treatment of pulmonary diffuse bullous disease, Sawabata et al. [14] have shown its capacity to induce a destructive degeneration of the visceral pleura. In an animal model, ABC has been tested to induce postoperative pleural symphysis and, although it has been reported as significantly less efficacious than talc or mechanical abrasion, Bresticker et al. [15] have found that ABC coagulation of the parietal pleura can ultimately induce a low degree of postoperative pleural adhesions. Recently, in a small series of patients, ABC has been successfully applied to the diaphragm surface to induce pleurodesis in recurrent hepatic hydrothorax [16]. Side effects from ABC use are rare; venous gas embolisms due to the gas jet have been reported during laparoscopic liver surface coagulation [17].

The results of our study obtained with pleural abrasion are similar to those previously reported, in terms of both the prevention of PSP recurrence and operative complications. On the other hand, the patients treated by ABC parietal pleural coagulation resulted as being exposed to a three-fold higher rate of recurrence with no benefits in the prevention of operative complications. In conclusion, although the statistical analysis failed to prove a significant difference between the two surgical procedures, the high rate of recurrence encountered in the group treated with ABC have induced us to abandon its use.

	Footnotes

 
Presented at the joint 19th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 13th Annual Meeting of the European Society of Thoracic Surgeons, Barcelona, Spain, September 25–28, 2005

	References

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

 

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This Article Abstract 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 Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bobbio, A. Articles by Rusca, M. Search for Related Content PubMed PubMed Citation Articles by Bobbio, A. Articles by Rusca, M. Related Collections Lung - other Pleura