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Eur J Cardiothorac Surg 2007;31:1106-1109. doi:10.1016/j.ejcts.2007.03.017
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
a Department of Thoracic Surgery, Rangueil-Larrey University Hospital, Toulouse, France
b Department of Thoracic and Cardiovascular Surgery, Montreal Heart Institute, Montreal, Quebec, Canada
Received 16 December 2006; received in revised form 10 March 2007; accepted 13 March 2007.
* Corresponding author. Address: Department of Thoracic Surgery, Larrey Hospital, 24 chemin de Pouvourville, TSA 30031, 31059 Toulouse Cedex 9, France. Tel.: +33 567 771 803; fax: +33 567 771 483. (Email: dahan.m{at}chu-toulouse.fr).
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Abstract |
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 Top Abstract 1. Introduction2. Patients and methods3. Results4. DiscussionReferences |
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Key Words: Pneumothorax • Pleurodesis • Silver nitrate • Video-assisted thoracoscopy
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1. Introduction |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionReferences |
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According to the consensus statement of the American College of Chest Physicians (ACCP), patients should be operated on at the second occurrence or in case of persistant air leaks >4 days [4,5]. Patients at risk (SCUBA divers, pilots, ...) should be operated on as soon as the first occurrence [4,5]. Although it is now agreed that thoracoscopy is the approach of choice for PSP [4–10], the optimal management of PSP is still controversial, especially in terms of the technique to be used [4,11]. The main goals of surgical treatment, which are pleurodesis and closure of the air leak, are achieved in most institutions by pleural abrasion, parietal pleurectomy or talc poudrage [13–15].
Chemical pleurodesis are mostly performed in case of persistant pleural effusion secondary to pleural metastasis or primary pleural neoplasms. Surgical chemical pleurodesis remains rarely performed [4,16]. Since the beginning of 1960s, we have been performing pleurodesis using silver nitrate solution with good results, and since the beginning of 1990s, we have been performing video-assisted thoracoscopic silver nitrate pleurodesis (VATSNP). The procedure is quick, inexpensive, safe and effective [17]. It is well tolerated by the patients and associated with low morbidity and low recurrence rates. The aim of this paper was to report our experience of thoracoscopic silver nitrate pleurodesis.
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2. Patients and methods |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionReferences |
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2.2 Surgical technique
After roentgenographic confirmation of pneumothorax, all patients underwent operation within the 24 h after admission. Indications for surgical pleurodesis were either ipsi-lateral recurrences, contro-lateral recurrences, hemo-pneumothorax, or bilateral PSP. Preoperative invasive procedures were only performed if large pneumothorax volumes led to patient discomfort.
All the patients were operated on under general anesthesia and single lung ventilation. Positioning consisted of lateral decubitus with upper limb hanging down. A sandbag was placed under the chest at the inferior scapular angle. Patients were draped to allow conversion to thoracotomy.
All surgeons of the department used a highly standardized videothoracoscopic technique. A 10-mm, 0° videothoracoscope (Distalcam VIMS Inc.) was introduced in the sixth intercostal space on the mid-axillary line through a 2-cm long skin incision. Under visual control, an additional incision was performed in the fourth intercostals space on the anterior axillary line so as to introduce endoscopic forceps, stapling device, and spraying catheter. After thorough inspection of the pleural cavity and the whole parenchymal surface, resection of bullae or blebs was performed by means of a linear endoscopic stapling device (Endo-GIA, Auto-Suture, Tyco Health Care). If no bullous area was seen, no pulmonary resection was performed. A solution of silver nitrate 1% (100–150 ml) was sprayed with a 15-cm long catheter attached to a 90° endoscopic grasper. The whole parietal, mediastinal, and diaphragmatic pleura were irrigated by the solution. Silver nitrate was not sprayed toward the visceral pleura so as to avoid lung damage. The pleural cavity was rinsed by saline irrigation (150–200 ml). Two chest tubes (Monaldy 18F) were placed through the two incisions. The first one was placed anteriorly and superiorly under visual control. The second was inserted posteriorly and inferiorly after removal of the optic. Both pleural tubes were connected to a water seal system (Pleur-Evac; Genzyme, Fall River, MA, USA) with –20 cm H2O suction.
2.3 Postoperative care
All patients were extubated in the operating room and transferred to the intensive care unit. Chest X-ray was performed to confirm good positioning of the chest tubes. Pulse oxymeter, blood pressure, and electrocardiogram were routinely monitored during the first 24 h. Antibiotics were administrated to all patients (Kefandol
® 750 mg daily for 48 h). Postoperative pain was controlled by means of preoperative rachianesthesia associated with acetaminophen, nonsteroidal anti-inflammatory medications and morphine. Pleural fluid loss was alternatively compensated from 500 ml by means of hydroxyethylamidon (until the dose of 33 ml/kg) and gelatines during the first 24 h. Patients were discharged from the intensive care unit 24–48 h after the operation and were transferred to conventional care unit. Daily chest roentgenogram was obtained for each patient. Chest tube removal was performed when good pleural apposition and absence of air leak and drainage <150 ml/24 h were obtained. All patients were discharged the day following the removal of chest tubes, if a normal chest roentgenogram was obtained.
2.4 Data collection and statistics
The patients were systematically followed up 1 month with clinical examination and chest X-ray. The last 250 patients were systematically recontacted at the time of the study for long-term follow-up. A standardized questionnaire was transmitted by phone by the clinic staff.
All the statistical studies were carried out using the STATA-PC program version 7.0 (Stata Corporation, Texas, USA). The continuous variables were expressed as mean ± standard deviation.
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3. Results |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionReferences |
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3.2 Intra-operative course
No intra-operative death or major complication occurred during or after the procedures. Bullae or blebs were diagnosed and stapled in 239 patients (39.6%), 96.5% were found within the upper lobe (93.6% had an apical location). Chemical pleurodesis was performed in all patients. Intra-operative complications occurred in 15 patients (2.5%), requiring conversion to thoracotomy (3 per-operative bleeding and 12 pleural adhesions). Mean operating time was 38.6 ± 10.7 min.
3.3 Postoperative course
Mean drainage time was 5 ± 4 days (range, 2–31) and mean drainage volume was 2196.5 ± 890.5 ml. Mean postoperative hospitalization time was 8 ± 5.4 days. Prolonged air leak (>7 days) was found in 94 patients (15.6%), 31 patients presented residual postoperative pneumothorax (5.1%), 15 patients postoperative pleural effusion (2.5%), 12 patients postoperative bleeding (2.0%), and 2 patients a transient Claude Bernard–Horner Syndrome. Twenty-one patients required invasive postoperative procedure (3.3%), 8 pleural punctions and 15 were reoperated on (12 bleeding and 3 prolonged air leak).
3.4 Follow-up
At 1 month, the follow-up was 100% complete, and the recurrence rate was 0.5% requiring either chest drainage (n
= 1) or reintervention (n
= 2). At long-term follow-up, the recurrence rate was 1.1%. One patient presented complete recurrence requiring reoperation and another patient presented partial recurrence, which spontaneously healed with rest. Three patients were reoperated on for other reason, and peri-operative constatations demonstrated diffuse pleurodesis, which, nevertheless, allowed partial lung resection on condition of careful dissection of pleural adhesions or extra-pleural dissection.
Return to occupation activity occurred at 54.1 ± 43.9 days. Residual moderate discomfort at the level of skin incisions were found in 34.9% of the patient at the time of follow-up, and 2.4% of the patients complained about an impression of respiratory limitation. The other patients were completely asymptomatic and returned to normal professional and leisure activities.
One patient presented a pulmonary hernia through the surgical approach.
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4. Discussion |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionReferences |
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Silver nitrate pleurodesis was first used in 1942 by Brock to produce aseptic pleural adhesion. In 1948, the same author advocated the production of a chemical pleuritis by injection into the pleural cavity, through an intercostals tube, 5–10 ml of a weak solution (2%) of silver nitrate followed by active suction on the drainage tube to rapidly re-expand the lung [18]. Since then, silver nitrate has only been used sporadically in this indication [19–20]. Factors that probably contributed to the decrease in use of silver nitrate include the development of a controversial exsudative effusion and pain associated with the procedure [18,21]. More recently, Vargas et al. [22] have demonstrated that a small concentration (0.5%) of silver nitrate instilled into the pleural space was effective for producing pleurodesis in the rabbit, and suggested silver nitrate could become the sclerosant agent of choice, given its wide availability and inexpensiveness. Since the beginning of 1960s, we have been performing pleurodesis with silver nitrate. This technique was first performed through thoracotomy approach, and since the beginning of 1990s, we have been performing video-assisted thoracoscopic silver nitrate pleurodesis.
We report a median follow-up period of 36.5 ± 28.7 months with an overall long-term recurrence rate of 1.9%, with only 1.0% of the patients requiring reoperation. Only few investigators have reported results with follow-up periods longer than 24 months [4,23], and the overall recurrence rate in patients treated through thoracoscopy approach range 3–9.4% using conventional surgical procedure, i.e. pleurectomy or pleural abrasion [7,9,11,13,24]. Some authors even pointed out that recurrence rate was higher after VATS compared to thoracoscotomy [7]. Thoracotomy with bullous disease resection and pleural abrasion or pleurectomy showed a recurrence rate requiring reoperation ranging between 0.5 and 1% [14].
Finally, video-assisted thoracoscopic silver nitrate pleurodesis provides as good long-term results as the gold standard which would remain open pleurectomy or abrasion. This efficacy is probably linked to the diffuse pleural treatment, which is only possible with chemical pleurodesis. The whole parietal, mediastinal, and diaphragmatic pleura are systematically treated.
Postoperative hemorrhagic complications constitute an unavoidable peri-operative and postoperative complications of pleural abrasion and pleurectomy [6]. Using video-assisted thoracoscopic silver nitrate pleurodesis, hemorrhagic complications were only found in 2.0% of the patients with 12 patients requiring reintervention and 3 patients (0.5%) requiring transfusions. At the beginning of our experiment, reintervention was achieved through thoracotomy approach, but more recently, these patients have been successfully reoperated on though thoracoscopic approach.
As reported by other authors about other surgical technique [6,25], the most frequent postoperative complication was prolonged air leak defined as prolonged drainage time over seven postoperative days. This complication was found in 15.6% of our patients. It is well known to be the most frequent postoperative complication, and we tend to perform reoperation earlier as at the beginning of our experiment, i.e., as soon as postoperative day 7 in case of persistent air leak.
The two main reported drawbacks associated with this technique were pain and abundant postoperative pleural effusion. In reality, the classical combination of rachi-analgesia and parenteral analgesia is adequate to control postoperative pain in all the patients. The compensation of liquid loss by macromolecules during the first 24 h is absolutely necessary, but no transfusion was required in the absence of postoperative hemorrhagic complication. Finally, the only constraint was a minimum 24-h stay in our intensive care unit so as to adjust analgesia and maintain normal volemia. This abundant postoperative pleural effusion suggests a strong inflammatory pleural reaction, making this technique very effective. Nevertheless, further surgery (lung cancer) and partial lung resection were performed in three patients without any difficulty.
Despite the limitations of this study mainly linked to its retrospective, monocentric and nonrandomized character, this study has several interests. First of all, it is, to our knowledge, one of the first reports available in the English literature dealing with the use of video-assisted thoracoscopic silver nitrate pleurodesis for PSP, with more than 600 patients treated over the past 10 years. It demonstrates safety and effectiveness of the procedure. Esthetical results (with only two centimetric axillary incisions) are acceptable in young patients presenting a benign pathology. Moreover, long-term results may be better than those reported after pleural abrasion and pleurectomy through thoracoscopic approach and equivalent to those of surgical treatment by thoracotomy. Video-assisted thoracoscopic silver nitrate pleurodesis may constitute an alternative to pleurectomy and pleural abrasion to treat patients with PSP. Nevertheless, the efficacy of thoracoscopic silver nitrate pleurodesis should be compared with that of other thoracoscopic techniques in multicentric randomized controlled studies in humans.
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References |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionReferences |
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