| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 2004;78:417-420
© 2004 The Society of Thoracic Surgeons
a Thoracic Surgery and Respiratory Services, Hospital de Gran Canaria "Dr. Negrín," Las Palmas de Gran Canaria, Spain
b Thoracic Surgery Service, Hospital Clinic, Barcelona, Spain
Accepted for publication November 25, 2003.
* Address reprint requests to Dr Freixinet, Thoracic Surgery Service, Hospital de Gran Canaria "Dr. Negrín," Barranco de la Ballena s, n, 35020 Las Palmas GC, Canary Islands, Spain
e-mail: jfregil{at}gobiernodecanarias.org
 |
Abstract |
|---|
 Top Abstract IntroductionMaterial and methodsResultsCommentAcknowledgmentsReferences |
|---|
METHODS: Patients were randomly assigned to two groups; video-assisted thoracoscopy (group A; n = 46) and axillary thoracotomy (group B; n = 44). All fit the established criteria for surgical indication (relapse or persistent air leakage after pleural drainage). In all cases the treatment consisted of apical segmentectomy of the blebs or dystrophic complex and pleural mechanical abrasion. The study evaluated the following factors: postoperative blood loss, respiratory function (maximum inspiratory and expiratory pressures, forced expiratory volume in the first second and forced vital capacity), postoperative pain (analog visual scale), supplementary doses of analgesics, postoperative complications, hospital stay, and resumption of normal activity. Relapses were evaluated for the minimum period of time of two years.
RESULTS: No significant differences were found in any of the factors studied in either group.
CONCLUSIONS: Video-assisted thoracoscopy and axillary thoracotomy offer similar results in the surgical treatment of primary spontaneous pneumothorax. The rate of complication is low and the level of pain is acceptable without long-term sequelae.
|
Introduction |
|---|
|
TopAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsReferences |
|---|
Since its introduction at the beginning of the 1990s, videothoracoscopy (VT) has been considered the ideal technique for the treatment of PSN [4–6], replacing classic axillary thoracotomy (AT) which up to then had been the technique most utilized with some good results. The differences between the two techniques, however, have not been firmly established. The objective of this article is to compare VT to AT, taking into account the factors, in practice, we consider most relevant.
|
Material and methods |
|---|
|
TopAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsReferences |
|---|
Patients were randomized into two groups: A (patients treated by VT) and B (patients treated by AT). Drainage tubes measuring 28F were used exclusively, inserted through the fifth intercostal space (in the case of treatment with pleural drainage) in the first episode of PSN. The interventions were done by senior staff thoracic surgeons using identical criteria. Videothoracoscopy was carried out with two ports, one of 5 mm and one of 12 mm. Circumscribed pulmonary leaks or blebs were located, grasped, and resected with an endostapling device. Pleural abrasion was performed with mesh spread over the entire apical surface of the parietal pleura. When closing the incisions, a 28F pleural drainage tube was placed and was connected to continuous aspiration. Axillary thoracotomy was carried out through a classic axillary muscle sparing incision of 7 to 10 cm. The rest of the operation was performed using the same procedures as in the VT operations, but without the use of endoscopic equipment. A 28F pleural drainage tube was placed in a separate wound. Concerning the financing of these procedures, the cost of personnel was the same for both, however AT uses, on average, two charges of stapling RL 30 (119.3 euros each) and VT uses two charges of endostapling 30 (150.4 euros each). There were no other differences in relation to the material used in the two techniques. Both operations had a similar duration of approximately 45 minutes.
All of the cases were treated with prophylactic antimicrobials for 24 hours (cefazolin 1 g at the start of anesthesia, followed by 1 g/6 hours). Metamizol (conventional nonsteroid analgesic) was used as a postoperative analgesic (2 g/6 hours endovenously for the two postoperative days, thereafter 0.6 g/6 hours orally until the seventh postoperative day). When supplementary analgesics were needed (level of pain higher than 7 in the analog visual scale), up to 3 doses per day of buprenorphine (0.3 mg intramuscular) were injected. No regimen, per se, of analgesics was prescribed to patients once they were discharged from the hospital. These were issued on demand in the postoperative period according to the patients' needs. All of the patients were given gastric protectors (ranitidine 50 mg/8 hours intravenously, thereafter 150 mg/12 hours orally until the seventh postoperative day). Pleural drainage was connected to continuous aspiration with a closed system under a water seal for a minimum of 48 hours. When there was no more pleural drainage, the drain was clamped and removed if there was no evidence of relapse. The patient was discharged, barring other complications, 24 hours after the removal of the drainage tube. Postoperative follow-ups included patient visits and roentgenograms, which were continued after one month, three months, one year, and two years.
The evaluation of the results of both techniques was carried out by measuring the following factors [1]: postoperative pain (analog visual scale with a 1 to 10 range), performed every 24 hours up to the seventh day, and at 15 days, one month, three months, six months, and one year (measured before application of pain medication) [2]; the amount of pleural drainage (postoperative blood loss) [3]; pulmonary function tests (maximum inspiratory and expiratory pressures and forced vital capacity) obtained on the fifth postoperative day [4]; the total amount of supplementary analgesic dosage [5]; postoperative complications [6]; the duration of the postoperative hospital stay [7]; day the patient resumed his (her) normal activities.
The Student's t tests were used for the statistical study, depending on conditions of application. The results are expressed as means with standard deviation. A significant value was taken as a p value less than 0.05.
|
Results |
|---|
|
TopAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsReferences |
|---|
Regarding postoperative pain, there were no significant differences for the seven day period after the operation. The level of pain on the first day was 3.8 ± 1.8 for group A and 4.1 ± 1.9 for group B and on the second day 2.9 ± 1.7 and 3 ± 1.3, respectively. Fifteen days after surgery the levels were 0.4 ± 1.0 and 0.2 ± 0.4. There were no differences in the measurements in the long-term follow-up; indeed, there was practically no pain associated with either technique three months after surgery.
We found no differences in postoperative air leaks between the two techniques. There were air leaks in three cases within group A, one of which was reoperated by AT. A disrupted bleb was identified and excised. No significant differences were obtained in the postoperative blood loss between the two groups (189 ± 145 mL for group A and 173 ± 133 for B). In no case was it considered excessive, and no reoperations for reasons of bleeding or residual hemothorax were carried out.
No significant differences were demonstrated in the measurements of postoperative pulmonary function: forced vital capacity (FVC) was 3,772 ± 1,131 mL (70.5% ± 3.0%) (group A) and 3,515 ± 1,020 mL (70.9% ± 3.9%) (group B); forced expiratory volume in the first second (FEV1) was 3363 ± 1,011 mL (77.9% ± 2.9%) (group A) and 3,037 ± 131 mL (73.1% ± 3%) (group B). Maximum inspiratory pressure was 66.5 ± 26.6 cm water (53.8% ± 3.8%) (group A) and 58.7 ± 20.6 cm water (47% ± 2.9%) (group B); maximum expiratory pressure was 66.7 ± 36.7 cm water (29% ± 2%) (group A) and 62.7 ± 23.9 cm water (28.2% ± 2.2%) (group B). The supplementary doses of analgesic required were 0.9 ± 2.9 for group A and 0.7 ± 1.9 for group B, with no significant statistical differences.
The postoperative complications were rare in both techniques (Table I). Together with the three previously mentioned cases of air leaks in group A, we should add two minimal persisting air spaces and a case of infection of the surgical scar in the VT group. In the AT group, the surgical scar of one patient became infected and two others had problems with shoulder mobility, which were solved with rehabilitation. Average postoperative hospital stay showed no significant differences, either, with 4.3 ± 2.1 days for group A and 3.9 ± 1.7 days for group B.
|
|
Comment |
|---|
|
TopAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsReferences |
|---|
The surgical technique employed was the most accepted by current surgical groups. The resection of blebs and mechanical pleural abrasion are the most frequently employed methods to resolve PSN, although there are groups that defend the use of pleurodesis with talc [4, 7]. Axilllary thoracotomy has been the classic surgical treatment of PSN, with many satisfactory results described in literature. The work of Deslauriers and colleagues [8] described a relapse index of 1%, a figure which agrees with the results of other authors [9]. The introduction of VT at the outset of the 1990s has made it the ideal treatment, describing good results right from its first published accounts [10]. At present, it is the preferred approach on patients with PSN [11]. Among its advantages are a shorter stay in the hospital and less postoperative pain; factors which, however, have been compared correctly in very few studies [12, 13].
One of the factors we considered to be of great importance in the study was postoperative pain. The figures for pain measured with the analog visual scale in the first few days after the operation were somewhat higher in the AT group, but without significant differences. The results are acceptable in both techniques when speaking of initial postoperative thoracic pain. In the long term we had no patients with significant residual pain. These results allow us to conclude that neither VT nor AT causes chronic postoperative thoracic pain. Nevertheless, these data conflict with recent studies that have found a high rate of chronic postoperative pain [14]. This complication is relatively frequent with other incisions and the consequences may be worrisome for the patient. The requirement for supplementary analgesics confirm our data, with low figures in both groups and no significant differences.
We did not find significant differences in the variables of respiratory function between groups A and B. However, we observed a trend towards a better pulmonary function in the patients who underwent VT, suggesting that an increase in the sample subjects could produce significant results.
We had very few postoperative complications in either group. In detail, there were three cases of persistent air leaks and two persisting pleural spaces in the VT group. In respect to factors for postoperative air leak days and blood loss due to drainage, we again found no significant statistical differences. We conclude that both interventions are reasonably nontraumatic, with little morbidity for the patient.
Another factor, which supports our conclusions, is the patients' hospital stay. The assertion that VT allows the patient to be discharged sooner is easily refuted if the data of this study, in which equal criteria for postoperative follow-up are used for the patients, are analyzed. The numbers were similar for both groups, with data for postoperative stay showing 4 to 5 days for both techniques, similar to recent studies [5, 15]. The patients' resumption of normal activities, data we consider relevant, took about one month, affirming the short recuperation period of both techniques.
One of the reasons AT is considered superior to VT is its relapse index. In our results the figures are conclusive, being the same in both techniques. Perhaps the fact of having experience with both, with an already acquired learning curve, has eliminated the possibility of relapses, a circumstance which is also voiced by other authors [16].
In summary, in this study we may conclude the following: (1) both techniques are equally useful and safe; (2) postoperative pain is easily controllable with conventional analgesics without chronic postoperative pain in the two techniques; (3) in both VT and AT the relapse index is very low; (4) in the two techniques hospital discharge and reincorporation into normal activities are similar, both being very acceptable.
|
Acknowledgments |
|---|
|
TopAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsReferences |
|---|
|
References |
|---|
|
TopAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  H. A. Vohra, L. Adamson, and D. F. Weeden Does video-assisted thoracoscopic pleurectomy result in better outcomes than open pleurectomy for primary spontaneous pneumothorax? Interactive CardioVascular and Thoracic Surgery, August 1, 2008; 7(4): 673 - 677. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Yamada, K. Yoshino, and H. Inoue Simultaneous Bilateral Spontaneous Pneumothorax With Pleural Window Communicating With Bilateral Pleural Spaces Ann. Thorac. Surg., April 1, 2008; 85(4): 1434 - 1436. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 N. Durrleman and G. Massard Axillary thoracotomy MMCTS, August 10, 2006; 2006(0810): 1834. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
