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Ann Thorac Surg 2003;76:1661-1664
© 2003 The Society of Thoracic Surgeons

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Original article: general thoracic

Video-assisted thoracic surgical treatment of initial spontaneous pneumothorax in young patients

^a Division of Cardiothoracic Surgery, George Washington University Medical Center, Washington, District of Columbia, USA
^b Division of Cardiothoracic Surgery, Georgetown University Medical Center, Washington, District of Columbia, USA
^c Division of Cardiothoracic Surgery, VAMC, Washington, DC, USA

^* Address reprint requests to Dr Alexander, Cardiothoracic Surgery, 2150 Pennsylvania Ave, Suite 6B, Washington, DC 20037
e-mail: ealexander{at}mfa.gwu.edu

Presented at the Forty-eighth Annual Meeting of the Southern Thoracic Surgical Association, San Antoinio, TX, Nov 8–10, 2001.

	Abstract

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
BACKGROUND: The treatment of primary spontaneous pneumothorax in young adults has been controversial. Conventional treatment consisting of chest tube thoracostomy may be associated with morbidity at the time of tube insertion, prolonged hospitalization, and interval operation in many patients. As spontaneous pneumothorax in young adults is usually associated with apical blebs, we hypothesized that video-assisted thoracic surgical (VATS) resection of the blebs at the time of the first pneumothorax may be an effective treatment associated with low morbidity and short hospital stays.

METHODS: From July 1992 to February 2001, 156 young adults were treated for spontaneous pneumothorax. Within 12 hours of presentation to the emergency department patients underwent semielective VATS with bleb resection and pleuradesis. During follow-up patients were observed for recurrent pneumothorax.

RESULTS: There were 69 men (44%) and 87 women (56%). The median age was 19 years old (range 14 to 38 years old). Patients were predominantly tall and thin. Patients were mildly symptomatic at the time of presentation. Apical blebs were seen in all patients and the presence of blebs was confirmed in the pathologic specimen. In 23 patients bleeding was associated with bleb rupture. There were no postoperative air leaks. The mean hospital stay was 2.4 ± 0.5 days. Follow-up ranged from 2 to 96 months (median 62 months). There were no recurrences on the index side.

CONCLUSIONS: VATS resection of apical blebs is associated with low morbidity and short hospitalization and provides an attractive alternative to the conventional treatment of initial tube thoracostomy and possible interval repeat thoracostomy or operation. VATS may be an effective first line treatment for spontaneous pneumothorax in young adults. Due to the pathophysiology of this disease, patients should be closely followed for the occurrence of pneumothorax on the contralateral side.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
Spontaneous pneumothorax (SP) is a relatively common disease with an incidence of between 4 to 9 per 100,000 population per year in the USA [1]. Typically, young adults developing spontaneous pneumothorax are otherwise healthy with no clinically apparent lung disease. These so-called primary pneumothoraces are distinct from secondary pneumothorax patients who have underlying pulmonary disease, most commonly chronic obstructive pulmonary disease (COPD) [2]. The approach to the patient with first time SP varies greatly, including observation, needle aspiration, tube thoracostomy, video-assisted thoracic surgery (VATS) or thoracotomy. Resection of bullae, pleuradesis, and apical pleurectomy are usually reserved for air leak persistence or intervening complications [3]. The most common approach, tube thoracostomy, may be associated with significant morbidity, prolonged hospitalization, and recurrence in a large group of patients. VATS provides an attractive alternative if it can be performed with safety and effectiveness. We describe our experience in the management of 156 young patients with an initial SP undergoing definitive primary management with VATS, resection of blebs, and pleuradesis shortly after their initial presentation.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
Patient population
Between July 1992 and February 2001, 156 young adults were treated for an initial SP. There were 69 males (44%) and 87 (56%) females. These patients were predominantly tall and asthenic and typically mildly symptomatic at presentation. Median age was 19 years (range 14 to 38 years). No computerized tomography (CT) scans were performed. Diagnosis was made by conventional chest radiographs. These patients were initially managed with admission and low flow nasal cannula oxygen without chest tube placement. Within 12 hours they underwent VATS, bleb resection, and pleuradesis.

Operative technique
A double-lumen endotracheal tube was placed routinely for single lung ventilation. Three incisions, approximately 2 cm in size, were made for camera and instrumentation access. Bleb resection was performed with stapled apical resection and was followed by pleuradesis to the visceral, parietal, and diaphragmatic surfaces using an electrocautery cleaning pad. Pleuradesis was performed so as to elicit petechial hemorrhage of the pleural surfaces without inducing excessive bleeding. Talc poudrage was then performed and a single 24 Fr apical chest tube was placed. Cryoanalgesia was performed at the access incision interspaces in the last 50 patients and the lungs were gently reinflated.

Subsequent course
Chest tubes were removed when drainage was less than 50 mL in an 8-hour period. Discharge generally followed shortly after chest tube removal. Follow-up instructions included counseling as to the bilateral nature of the disease and the possible need for additional surgery on the contralateral side.

	Results

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
All patients were successfully managed with a VATS approach. Apical blebs were evident at VATS in all patients and were confirmed by pathologic examination. The specimen typically consisted of an inverted U-shaped segment of lung consisting of the border of the involved lobe. In 23 patients hemosiderin was evident in the resected specimen, consistent with recent rupture and hemorrhage. There were no air leaks at 24-hours postoperatively. There were no wound infections, early recurrences, or readmissions. The mean hospital stay was 2.4 ± 0.5 days (range 1 to 5 days).

Follow-up
Follow-up ranged from 2 to 96 months with a median of 62 months. Follow-up was performed by clinic visits as well as telephone interviews. No patients were lost to follow-up. There were no recurrences on the operated side during the follow-up period.

	Comment

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
Primary spontaneous pneumothorax occurs predominantly at rest in tall, thin individuals with an average age from 15 to 30 years old [4]. Males are usually more commonly afflicted than females, the reason for the inverted ratio in our study is not apparent. These patients are mildly symptomatic due to their otherwise normal lungs and pulmonary reserve. Frequent thoracoscopic evaluation of primary pneumothorax reinforces the observation that this disorder is regularly associated with apical subpleural blebs or bullae.

The presence of apical blebs or bullae has been previously described in this group of patients [5], and likely constitutes the basis for recurrence in most patients. The incidence of recurrence in this cohort of patients varies from 16% to 52% [3], with an average of around 30%. It is difficult to predict which patients are most likely to suffer a recurrence. Risk factors such as male sex, smoking, and younger age have been identified [6]. CT scanning for predicting recurrence has been proposed. Some authors advise that patients with emphysematous changes be offered recurrence prevention at an earlier stage [7]. CT evidence of blebs or bullae is, however, not uniformly accepted as predictive of a recurrence [8].

Observation, aspiration, and tube thoracostomy do not address the underlying pathophysiology and do not provide any definitive recurrence prevention. At least 40% of patients may ultimately require surgery [9, 10]. Schramel and coworkers [11] suggested that immediate VATS and recurrence prevention might be more cost-effective than more conservative treatment options. Baumann and Strange [12] proposed recurrence prevention for all patients suffering a SP. Torresini and colleagues [13] concluded that an initial definitive approach was justified in the interests of both patients and health organizations. However, in the American College of Chest Physicians (ACCP) consensus statement from 2001, only 15% of participants felt that patients should be managed in this fashion [14].

VATS has several advantages over conventional or limited axillary thoracotomy, including less postoperative pain, better cosmesis, less physiologic trauma, and better postoperative pulmonary function [15]. Economical advantages of VATS have also been demonstrated [13]. Success of any operative approach is predicated on the control of postoperative air leaks, reported to occur in 2.7% to 8% with VATS approaches, using a variety of operative techniques [9, 10, 13, 16]. The absence of air leak and recurrence in this series may be attributed to a number of intraoperative technical maneuvers. These include complete visualization of the lungs using VATS, use of the endostapler, stapling across otherwise healthy lungs, and gentle reinflation of the lung at the termination of the procedure, minimizing tears at the staple line. Additionally, pleuradesis creates a reliable pleural symphysis and addresses any possible missed blebs or bullae.

Length of stay following thoracotomy for pneumothorax is largely dependent on the presence of air leak. The length of stay in this study compares favorably with other series of thoracotomies and VATS procedures [7, 9, 10, 13, 16–17], and is a consequence of the absence of air leak early postoperatively.

Most recurrences occur within 2 years following surgery. Our recurrence rate compares favorably with recurrence rates of less than 1% for open approaches [18], and rates of 0% to less than 5% for VATS procedures [19, 20]. The talc poudrage used in this series was added to mechanical pleural abrasion to effectively eliminate air leak and recurrence. There was no instance of respiratory failure, or obvious untoward effects of the talc in this series as has been reported in other series [21]. Pericardial strips were not used, as staple lines typically traversed normal lung tissue. Our current practice has evolved to include the use of Focalseal to support staple lines [22].

VATS resection of apical blebs results in low morbidity and short hospitalization. Further study including a randomized trial, with recurrence and cost analysis, is warranted to definitively establish an ideal management strategy for young patients with primary spontaneous pneumothorax.

	Discussion

Top Abstract Introduction Patients and methods Results Comment Discussion References

 
DR ROBERT J. CERFOLIO (Birmingham, AL): A couple of quick questions. First of all, could you address using talc in all your young patients? Second, you have applied a strategy because we have a new surgical technique. That would be like doing a laparoscopic antireflux procedure on everyone with a hiatal hernia. Don’t you think our surgical indications should stay the same regardless of our technique? Why not, like we do, use the size of the air leak to stratify which patients would benefit from operation and avoid the cost of surgery in the others? If they had a real small air leak, why not just watch those patients. Many patients’ leaks stop in 1 to 2 days and go home and they never recur. Finally, it always raises a red flag when we see the words "all", "never"—can you comment on how all your patients, everyone single one had a bleb, we often never see a bleb—how no patient had a complication—and how no patient had a recurrence? Thanks.

DR MARGOLIS: In terms of the talc, we are aware of the data regarding the use of talc and the possibility, which is not always confirmed or agreed upon, of respiratory failure with talc. We basically use talc as an additional preventive type measure to try and prevent any recurrences, to address any possibility of a missed pneumothorax, but we are aware of that data regarding the talc. We had no episodes of any respiratory failure in the 156 patients.

In terms of the surgical indications, the reason we took this approach is that the average recurrence in the literature is quoted at around 30%. I know there are varying figures. About 10% of patients who do end up getting a tube thoracostomy will fail the tube thoracostomy, and there is also a percentage of patients who will have a prolonged air leak. Even if they ultimately go home after a tube thoracostomy, they will be in the hospital for a long time with the associated morbidities. We have shown that these are young patients. They are at risk for recurrence. We can do this with a very low morbidity and a very safe approach. So we feel that this is something that needs to be considered as appropriate management for these young patients.

The third question, in terms of the size of the leak, we did not quantify the size of the leak because we didn’t see the leak. They had no chest tubes placed before they went to the OR.

DR LYNN H. HARRISON (New Orleans, LA): I am surprised that you were able to find evidence of blebs in every single one of this consecutive series. That has certainly not been the experience that we have had or the experience of any other report that I know of.

And I would emphasize what Dr Cerfolio has said. I think you need to think further ahead in terms of your use of talc. The talc pleurodesis achieves a pleural symphysis that is only slightly less dense than that of pleurectomy. I am sure a number of these patients were smokers, and eventually some of them are going to come back with a coin lesion or primary lung cancer, and I don’t envy the surgeon who has to go in and operate on that patient. I think the talc is an unnecessary adjunct to what is otherwise very effective treatment.

DR JOSEPH I. MILLER (Atlanta, GA): First, I have two questions, but looking at any operation historically, you have just reported the lowest incidence of recurrence ever reported. In 1992 at the First World Congress on VATS, there was an 11% reported recurrence with VATS used for pneumothoraces. In 1994 at the Third World Congress, that incidence had been lowered to 7%, and that was multigroups reporting. In 1995, through a study carried out through the American College of Surgeons headed by Valerie Rusch, multiple institutions reporting, that had been lowered to about 2%. The transaxillary approach historically has a 1% to 2%, and the open, less than 0.5%. I wonder if you can tell us or do you attribute this to the talc that you have the lowest reported recurrence ever reported for pneumothoraces?

Number two, it is almost unheard of that you would see blebs in all patients. I am fairly familiar with the last 20 years and the last 10 years of the literature regarding VATS for that, and there are a number of reports where they are not seen, but you go ahead and resect what you think are apical blebs, and, granted, you confirmed it, but it is a unique report. I just wonder if you could address that because I don’t think anybody else in this room has had that experience. Thank you.

DR MARGOLIS: With regard to the bleb issue, this was our findings at surgery and this was the finding at pathology. So I am not certain why all our patients did in fact have blebs. I cannot answer that question.

With respect to the recurrence rate, there are one or two other VATS series, which are small numbers, that do report a zero recurrence rate with a shorter follow-up than ours. We feel there are a number of factors in our approach that allow us to have a zero leak, which is associated with a zero recurrence rate. First of all, we are operating on patients that have had no chest tubes in, they have healthy surrounding lungs, and we are able to staple across these normal lungs very effectively. We use the Endo stapler. We don’t use any of the other Endo loop or laser techniques. We feel that with the VATS we are able to visualize the whole lung. We see any blebs that are there and we address those. There is no issue of any missed blebs. With a limited axillary thoracotomy, you may miss a few blebs.

The other things that we do feel are associated with our zero recurrence is the fact that we gently reinflate the lung at the end of the procedure, we eliminate the risk of tearing at the staple line, which has been shown in other series, and then I think something which is important in our zero recurrence is the fact that we did use the talc and the mechanical pleurodesis.

DR TODD L. DEMMY (Columbia, MO): I noted in the abstract book that you had 83% of the patients return with a contralateral pneumothorax. That seems to be a lot higher than other reports. Is there something different about your population or your management that might account for this?

Regarding talc, it has also been shown both clinically and experimentally that a dose of intrapleural talc distributes to every organ in the body that may be a concern for patients with benign disease.

DR MARGOLIS: Unfortunately that figure of 83% is not accurate and that is why it did not appear on the paper over here. What happened was that that number was mixed with a certain percentage of patients that chose to come back for elective surgery on the opposite side. So that is a skewed number. That is not an accurate percentage of recurrences on the opposite side.

DR ALAA Y. AFIFI (Albany, NY): I had a similar question. Although you did not address it, if the incidence was truly 83%, you might consider admitting every patient who presented with a pneumothorax and perform a bilateral blebectomy or exploratory VATS and pleurodesis; however, you made the correction and larified your point. Thank you.

	References

Top Abstract Introduction Patients and methods Results Comment 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 Author home page(s): Marc Margolis Farid Gharagozloo Barbara Tempesta Gregory D. Trachiotis Nevin M. Katz E. Pendleton Alexander Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Margolis, M. Articles by Alexander, E. P. Search for Related Content PubMed PubMed Citation Articles by Margolis, M. Articles by Alexander, E. P. Related Collections Lung - other