Lung wedge resection improves outcome in stage I primary spontaneous pneumothorax

doi:10.1016/j.athoracsur.2003.10.057

The Annals of Thoracic Surgery

Volume 77, Issue 5, May 2004, Pages 1802-1805

https://doi.org/10.1016/j.athoracsur.2003.10.057 Get rights and content

Abstract

Background

To evaluate the role of apical lung wedge resection in patients with recurrent primary spontaneous pneumothorax with no endoscopic abnormalities at surgery as compared with simple apical pleurectomy.

Methods

We performed a retrospective analysis on 126 consecutive video-assisted thoracoscopic surgery (VATS) procedures in 113 patients treated for stage I recurrent PSP between January 1994 and December 2001. Two surgical strategies were applied: simple apical pleurectomy (57 procedures, 45.2%: group A) and apical pleurectomy together with an apical lung wedge resection (69 procedures, 54.8%: group B).

Results

Mean duration of chest tubes was 1.4 days (range, 1 to 7), mean hospital stay was 2.4 days. Three patients (2.4%) required redo VATS, 2 in group A (3.5%) for persistent air leak and 1 (1.4%) in group B for apical hematothorax. Mean follow-up was 38.7 months. Overall recurrence rate was 3.2%. Four patients in group A (7%) experienced recurrent ipsilateral pneumothoraces 4 to 73 weeks (mean, 30.2) after surgery. No recurrences were observed in group B (p = 0.009).

Conclusions

In this selected group of patients without endoscopical abnormalities, VATS offers low recurrence rates. However, these data suggest that apical pleurectomy should be accompanied by apical lung wedge resection even for this favorable category of patients.

Section snippets

Patients and methods

Between January 1994 and December 2001, 206 consecutive procedures were performed in 182 patients (75% male; mean age, 35.3 years; range, 14 to 80) for recurrent spontaneous pneumothorax. Analysis was by case history, chest computed tomography (CT) scan, operation report, pathologic report, chest tube duration, length of stay and outpatient follow-up. Vanderschueren's classification was used to determine the extent of morphologic alterations: stage I no endoscopic abnormalities, stage II

Clinical outcome

A total of 126 apical pleurectomies were performed in 113 patients. Of these, 13 patients had a second VATS procedure for PSP in the other lung after a mean period of 25 weeks (range, 0 to 114). Three patients (2.4%) required redo VATS, 2 in group A (3.5%) for persistent air leak and 1 (1.4%) in group B for apical hematothorax (p = 0.431). Chest tubes were removed after a mean duration of 1.4 days (range, 1 to 5) in group A and after 1.6 days (range, 1 to 7) in group B (p = 0.259). The mean

Comment

In this selected group of patients without endoscopical abnormalities, VATS offers low recurrence rates through a minimally invasive approach. However, these data suggest that apical pleurectomy should be accompanied by apical lung wedge resection even in this favorable category of patients.

The presence of subpleural blebs is a common finding during chest surgery 1, 14, 15, 16, 17, 18, 19. However, the evidence of bullae during the evaluation of a primary spontaneous pneumothorax (PSP) is not

References (23)

J.R Campos et al.
Respiratory failure due to insufflated talc
Lancet
(1997)
P.C Bertrand et al.
Immediate and long-term results after surgical treatment of primary spontaneous pneumothorax by VATS
Ann Thorac Surg
(1996)
L Lang-Lazdunski et al.
Videothoracoscopic bleb excision and pleural abrasion for the treatment of primary spontaneous pneumothoraxlong-term results
Ann Thorac Surg
(2003)
A.K Ayed et al.
The results of thoracoscopic surgery for primary spontaneous pneumothorax
Chest
(2000)
R.G Inderbitzi et al.
Three years' experience in video-assisted thoracic surgery (VATS) for spontaneous pneumothorax
J Thorac Cardiovasc Surg
(1994)
D.M Donahue et al.
Resection of pulmonary blebs and pleurodesis for spontaneous pneumothorax
Chest
(1993)
M Ikeda et al.
Median sternotomy with bilateral bullous resection for unilateral spontaneous pneumothorax, with special reference to operative indications
J Thorac Cardiovasc Surg
(1988)
E.C Werebe et al.
Systemic distribution of talc after intrapleural administration in rats
Chest
(1999)
M Ohata et al.
Pathogenesis of spontaneous pneumothoraxwith special reference to the ultrastructure of emphysematous bullae
Chest
(1980)
F.M Schramel et al.
Current aspects of spontaneous pneumothorax
Eur Respir J
(1997)

S.A Sahn et al.

Spontaneous pneumothorax

N Engl J Med

(2000)

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Can preoperative imaging studies accurately predict the occurrence of bullae or blebs? Correlation between preoperative radiological and intraoperative findings
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Citation Excerpt :
However, 9–29% of patients undergoing surgery for PSP do not have ELCs, and these patients have a lower postoperative cure rate [2,3,6]. Intraoperative findings are important for determining the surgical procedure performed and for predicting the prognosis [7], but the usefulness of preoperative imaging studies in PSP patients is unclear. According to guidelines for the management of PSP [8,9], routine chest computed tomography (CT) is not recommended, because it is not useful for predicting the recurrence of pneumothorax, identifying the cause of a persistent air leak, or deciding the type of surgical intervention.
Radiological findings of patients with primary spontaneous pneumothorax (PSP) undergoing surgery have not been well analyzed. The aim of this study was to evaluate the accuracy of imaging studies for predicting the presence of emphysema-like changes (ELCs) detectable during surgery.
Ninety-three PSP patients who underwent surgery from September 2005 to October 2009 were included in the study. We analyzed preoperative chest radiographic and computed tomographic (CT) findings, and compared the findings with intraoperative detection of ELCs. Chest radiographic findings were analyzed by classifying the PSP size into three categories: small, moderate, and complete.
Seventy-six of the 93 patients (82%) had ELCs detected during surgery. The size of the PSP on a radiograph was significantly correlated with the presence of ELCs (p=0.0121). Preoperative CT revealed 64 of the 76 ELCs (sensitivity, 84%; specificity, 100%; accuracy, 87%). Twenty-nine patients without ELCs detected by preoperative CT were analyzed separately. In this group, a larger PSP size also increased the likelihood of ELCs being present (p=0.0049). Seven patients (8%) experienced a recurrence after surgery. No factor could significantly predict recurrence.
Chest CT analysis alone was associated with a false-negative rate of about 15% for ELCs. Combining the analysis of chest radiographic and CT findings could improve sensitivity.
Efficacy of polyglycolic acid sheet after thoracoscopic bullectomy for spontaneous pneumothorax
2013, Annals of Thoracic Surgery
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This procedure is performed by partial excision of the apical parietal pleura. However, we do not use this procedure because it can lead to postoperative complications such as bleeding [4, 14, 17, 18]. Intraoperative chemical pleurodesis has an acceptable recurrence rate of 1.9% to 5.7%.
Various procedures have been performed to decrease the incidence of recurrent postoperative pneumothorax after thoracoscopic bullectomy. The purpose of this study was to determine the efficacy of a polyglycolic acid (PGA) sheet and pleural abrasion for prevention of recurrent postoperative pneumothorax.
From January 2009 to August 2011, 257 patients underwent thoracoscopic bullectomy for primary spontaneous pneumothorax. In group A, 128 patients underwent pleural abrasion. These patients were compared with 129 patients (group B) who underwent a procedure to cover stable lines with an absorbable PGA sheet in addition to pleural abrasion.
There was no difference in preoperative demographics, although the age of patients in group A was statistically higher than that of patients in group B (23.67 ± 6.54 versus 21.69 ± 5.65; p = 0.010). In group A, prolonged postoperative air leaks (≥ 3 days) occurred more frequently (7.8% versus 2.3%; p = 0.045). A Kaplan-Meier curve showed that recurrence-free rates were higher in group B (p = 0.047).
Coverage with PGA sheet and pleural abrasion after thoracoscopic bullectomy is effective for preventing prolonged postoperative air leaks and reducing postoperative recurrence rates.
Cause and management of recurrent primary spontaneous pneumothorax after thoracoscopic stapler blebectomy
2011, Asian Journal of Surgery
As the number of patients treated by thoracoscopic stapler blebectomy increased, the postoperative recurrence rate had risen unexpectedly. We retrospectively investigated the cause and management of primary spontaneous pneumothorax recurrence after thoracoscopic stapler blebectomy.
From March 1992 to the end of December 2006, thoracoscopic stapler blebectomy was performed in 357 patients with primary spontaneous pneumothorax at the Nihon University Itabashi Hospital. The causes and management of recurrence were investigated in 30 patients with postoperative recurrence based on items such as the resurgical observations, preoperative chest computed tomography findings, previous operative notes.
Among the patients with bilateral pneumothorax, young patients exhibited a higher tendency for postoperative recurrence. The most common cause was new bulla formation (28 slides, 16 of which were apparently related to the staple line and 12 of which were not related to the staple line).
In thoracoscopic stapler blebectomy for primary spontaneous pneumothorax, the most common cause of recurrence was new bulla formation. It is necessary to establish additional procedures involving either the visceral pleura or the parietal pleura to reduce the recurrence rate.
Treatment specifics for spontaneous pneumothorax in flight personnel
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Un pneumothorax spontané est une cause d’inaptitude aéronautique chez le personnel navigant (PN), en raison du risque de récidive en vol mettant en jeu la sécurité aérienne. Un traitement spécifique est nécessaire pour les pilotes de chasse, les pilotes ayant une activité en monopilote et les élèves-pilotes : une symphyse chirurgicale par vidéo-thoracoscopie est obligatoire dès le premier épisode. Compte tenu de l’exposition à un cumul de facteurs aéronautiques susceptibles de favoriser une récidive de pneumothorax en vol, c’est un geste associant pleurectomie apicale, abrasion du reste de la plèvre et résection de bulles/blebs apicaux qui est exigé chez les pilotes de chasse afin de leur permettre de recouvrer une aptitude aéronautique sans restrictions. Pour les autres catégories de PN, la prise en charge ne diffère pas de celle du patient « ordinaire ». La connaissance de ces spécificités de prise en charge par le pneumologue est primordiale, pour éviter de poser inutilement une indication chirurgicale systématique chez tous les PN, ou de mettre en jeu l’aptitude professionnelle de certains d’entre eux par un traitement inapproprié.
Spontaneous pneumothorax is one cause of aeronautical unfitness in flight personnel, because of the risk of recurrence in flight, making it an issue of flight safety. Specific treatment is required for fighter pilots, pilots flying single-pilot and pilots in professional training: surgical synthesis via video-thoracoscopy is obligatory from the first episode. Considering the exposure to an accumulation of aeronautical factors that are likely to encourage pneumothorax recurrence in flight, it is apical pleurectomy together with abrasion of the remaining pleura and resection of bullae/blebs that is required for fighter pilots to allow them to recover aeronautical fitness unrestrictedly. For all other categories of flight personnel, treatment is no different from that of the common patient. Knowledge of these treatment specifics is essential, to avoid unnecessary systematic surgical indication for all flight personnel, or jeopardise professional fitness in some of them due to inappropriate treatment.
Population-based study on surgical care for primary spontaneous pneumothorax
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Original article: general thoracicLung wedge resection improves outcome in stage I primary spontaneous pneumothorax

Abstract

Background

Methods

Results

Conclusions

Section snippets

Patients and methods

Clinical outcome

Comment

Lancet

Ann Thorac Surg

Ann Thorac Surg

Chest

J Thorac Cardiovasc Surg

Chest

J Thorac Cardiovasc Surg

Chest

Chest

Current aspects of spontaneous pneumothorax

Eur Respir J

Spontaneous pneumothorax

N Engl J Med

Original article: general thoracic
Lung wedge resection improves outcome in stage I primary spontaneous pneumothorax