A Limited Axillary Thoracotomy as Primary Treatment for Recurrent Spontaneous Pneumothorax

doi:10.1378/chest.103.1.137

Chest

Volume 103, Issue 1, January 1993, Pages 137-142

https://doi.org/10.1378/chest.103.1.137 Get rights and content

Recurrent spontaneous pneumothorax often requires surgical treatment following variable periods of chest tube therapy. A limited axillary thoracotomy provides sufficient exposure to isolate or excise pulmonary blebs and perform a pleurodesis. Prompt use of this surgical approach in lieu of the initial placement of a thoracostomy tube avoids prolonged hospitalization and a significant failure rate of thoracostomy tubes to resolve this problem. This operation can also prevent recurrence, a significant problem for this pathologic process. Fourteen patients with recurrent spontaneous pneumothorax underwent an axillary thoracotomy as either primary treatment or within 72 h of thoracostomy tube placement. The average follow-up was 38 months for the initial 10 patients and 23 months for the entire group. The procedure averaged 66 min in duration. The average incision was 3.3 cm in length. There was an equal male/female ratio and right-left distribution. The patients were discharged an average of 4.2 days after surgery. There were no complications. The most recent six patients with a recurrent pneumothorax were surgically treated on the day of admission without a preoperative chest tube. The other eight patients had a thoracostomy tube for control of the pneumothorax, with surgery performed within 72 h of tube placement. A limited axillary thoracotomy corrected the underlying pathology, hastened hospital discharge, limited pain, prevented short-term recurrence, and was cosmetically acceptable. A limited axillary thoracotomy is the operation of choice when a spontaneous pneumothorax requires surgery. This surgical approach has become our primary treatment for recurrent pneumothorax, avoiding the use of a preoperative thoracostomy tube and unnecessary delay, with excellent results for the patient.

Section snippets

MATERIALS AND METHODS

This report analyzes the first 14 patients who underwent a limited axillary thoracotomy for a recurrent spontaneous pneumothorax. The first ten patients provided follow-up for more than 3 years after surgery, while the entire population averaged follow-up for more than 2 years. The length of time for the initial ten patients provided sufficient data assessing recurrence, since the majority of new pneumothoraces develop within 2 years of the initial event.⁶ Selection criteria for using a limited

RESULTS

Thirteen patients had had one previous spontaneous pneumothorax, and one patient had had two previous episodes (Table 1). These initial episodes of pneumothorax were treated with a thoracostomy tube in 11 patients and by observation in 2 patients, and a single patient underwent a standard posterolateral thoracotomy following prolonged and unsuccessful use of a thoracostomy tube. This last patient most recently presented with a symptomatic spontaneous pneumothorax on the contralateral side from

DISCUSSION

Spontaneous pneumothorax is a medical problem of young adults that affects a significant portion of the population.1, 7 The most common etiology in this population is the rupture of congenital pulmonary blebs, which occur primarily on the apex of the upper lobes.¹ Although this problem has the rare potential for mortality, in the form of a tension pneumothorax,⁸ the more common consequences for the patient are associated with the treatment of this problem; and they include the pain of a

REFERENCES (14)

J Deslauriers et al.
Transaxillary pleurectomy for treatment of spontaneous pneumothorax
Ann Thorac Surg
(1980)
A. Wakabayashi
Thorascopic ablation of blebs in the treatment of recurrent or persistent spontaneous pneumothorax
Ann Thorac Surg
(1989)
M Torre et al.
Nd:YAG laser pleurodesis through thoracoscopy: new curative therapy in spontaneous pneumothorax
Ann Thorac Surg
(1989)
JP O'Rourke et al.
Civilian spontaneous pneumothorax treatment options and long-term results
Chest
(1989)
J Lechter et al.
Spontaneous pneumothorax in young subjects
Thorax
(1971)
D Weeden et al.
Surgical experience in the management of spontaneous pneumothorax 1972–82
Thorax
(1983)
GobbelWA et al.
Spontaneous pneumothorax
J Thorac Cardiovasc Surg
(1963)

There are more references available in the full text version of this article.

Cited by (33)

Pneumothorax and Barotrauma
2008, Critical Care Medicine: Principles of Diagnosis and Management in the Adult
Axillary thoracotomy versus videothoracoscopy for the treatment of primary spontaneous pneumothorax
2004, Annals of Thoracic Surgery
Citation Excerpt :
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].
A prospective, randomized study was carried out on patients with primary spontaneous pneumothorax, with the aim of determining if video-assisted thoracoscopy is superior to axillary thoracotomy in the surgical treatment of this condition.
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.
No significant differences were found in any of the factors studied in either group.
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.
An audit of medical thoracoscopy and talc poudrage for pneumothorax prevention in advanced COPD
2004, Chest
Citation Excerpt :
These results concurred with those reported by Liu et al,22 of a group of 13 patients (age range, 55 to 71 years) with diffuse emphysematous lung disease and persistent SP who were treated with thoracoscopic talc insufflation without bullectomy, and were observed for 22 months. In addition, the duration of tube drainage, length of hospital stay, and immediate and long-term success were comparable with those after treatment with VATS and staple bullectomy,1727 as well as limited thoracotomy.28 Although fever was observed within 48 h of undergoing MT-TP in five patients (12%), blood culture findings were negative, and there was no occurrence of postoperative empyema.
To prospectively study all patients with COPD and spontaneous pneumothorax (SP) who underwent thoracoscopic talc poudrage (TP) under local anesthesia to determine its efficacy and safety in recurrence prevention.
Data on clinical measurements, complications, duration of chest tube drainage, length of hospital stay, and outcome were collected.
Forty-one patients (38 men and 3 women) with a mean (± SD) age of 70.7 ± 7.2 years were treated. All patients had COPD, with a mean FEV₁ of 41 ± 14% predicted. The majority of SPs measured 20 to 50% in size, and 34% were recurrent. Three grams of talc were insufflated into the pleural cavity without complications. Thirteen patients (32%) complained of pain, 5 (12%) developed fever, 27 (66%) had subcutaneous emphysema, and 7 (17%) had prolonged air leaks. Postoperative chest tube drainage and hospital stay were 4 and 5 days, respectively. Success was 95% after a median follow-up of 35 months. Four patients with FEV₁ of < 40% predicted died within 30 days of the procedure, yielding a mortality rate of 10%. FEV₁ (in liters), FEV₁ (in % predicted), and ischemic heart disease were risk factors that influenced early mortality.
Thoracoscopic TP is effective for pneumothorax prevention and can be performed with acceptable mortality in patients with advanced COPD.
The results of thoracoscopic surgery for primary spontaneous pneumothorax
2000, Chest
To review our experience of video-assisted thoracoscopic surgery for the treatment of primary spontaneous pneumothorax.
Longitudinal cohort study following up consecutive patients for 3 to 4.3 years.
Thoracic Surgery Department, Chest Diseases Hospital, Kuwait.
Seventy-two consecutive patients undergoing thoracoscopy for primary spontaneous pneumothorax from January 1994 to June 1996.
The mean age of the patients was 25 years (range, 15 to 40 years), and 67 were men (93%). All patients were successfully treated using video-assisted thoracoscopic technique. Recurrent pneumothorax was the most frequent indication for surgery, occurring in 49 patients. The most common method of management was stapling of an identified bleb, which was done in 56 cases. Pleurodesis was achieved by gauze abrasion (n = 39) and apical pleurectomy (n = 33). Postoperative prolonged air leak occurred in five patients (6.9%). There were no deaths attributable to the procedure. The mean (±SD) postoperative hospital stay was 4 ± 2 days. Mean follow-up is 42 months (range, 36 to 54 months) for all patients. Pneumothorax recurred in four patients (5.5%) in whom pleural abrasion was done. The recurrences occurred in the first year of follow-up, three required a reoperation, and one healed by rest without pleural drainage.
Video-assisted thoracoscopic surgery is a safe procedure in the treatment of primary spontaneous pneumothorax. Apical pleurectomy is a more effective way of producing pleural symphysis. Long-term follow-up did not increase the rate of recurrence.
A comparison of thoracoscopic talc insufflation, slurry, and mechanical abrasion pleurodesis
1997, Chest
The purpose of this study was to compare the anatomic and histopathologic results of four different methods of pleurodesis in 10 dogs. Each animal was randomly assigned to receive two of the following methods of pleurodesis: thoracoscopic talc insufflation (poudrage), talc slurry administration, focal gauze abrasion by limited thoracotomy, and mechanical abrasion by thoracoscopy using a commercially available pleural abrader. Animals were killed 30 days after pleurodesis. At autopsy, the efficacy of pleurodesis was graded by evaluating the gross appearance of each pleural cavity and lung (pleurodesis score), and by determining the extent of adhesion formation (obliteration grade). Pleural and lung biopsy specimens were obtained from the areas most representative of adhesion formation for histopathologic evaluation. Pleurodesis scores (on a scale of 0 to 4) were 3.0±0.7 for talc poudrage (p<0.05 when compared with talc slurry), 2.2±1.7 for thoracotomy, and 1.6±1.1 for talc slurry. Adhesions produced by gauze abrasion during thoracotomy were mostly peri-incisional. Thoracoscopic pleural abrasion using the pleural abrader was uniformly unsatisfactory. Granulation tissue formation was greatest in both talc models. The degree of parietal pleural thickening was greatest in the talc slurry model, but fibrosis and inflammation occurred mostly in gravity-dependent areas within the pleural cavity. Although differences were not statistically significant, thoracoscopic talc insufflation consistently produced the most widespread, firm fibrotic adhesions as evidenced by higher obliteration grades.
Immediate and long-term results after surgical treatment of primary spontaneous pneumothorax by VATS
1996, Annals of Thoracic Surgery
Video-assisted thoracic surgery has recently evolved as a viable alternative to thoracotomy for spontaneous pneumothorax.
A series of 163 patients with primary spontaneous pneumothorax were treated by video-assisted thoracic surgery. Seventy patients were treated for a recurrent episode, 64 patients for a persistent primary spontaneous pneumothorax, 24 patients for a contralateral episode, and 5 patients for a bilateral primary spontaneous pneumothorax. Stapling of bullae with an Endo-GIA stapler (Auto-Suture, Elencourt, France) was performed in 90% of the cases and parietal pleural abrasion was performed in each case.
One revisional lateral limited thoracotomy was required for bleeding. Six patients had a prolonged air leak; 2 of them were reoperated on by lateral limited thoracotomy. Two patients have had an incomplete reexpansion of the lung and required a reoperation. The duration of hospitalization was 6.9 ± 3 days. With a mean follow-up of 24.5 months, three recurrences requiring a reoperation occurred; 3 other patients had a partial recurrence and healed by rest without drainage. The mean time to return to the occupational activity of the patients was 42 ± 34 days. These results were compared with those of a previous series of 87 patients operated on by lateral limited thoracotomy.
With the development of surgical technique and video equipment, video-assisted thoracic surgery will probably become the treatment of choice of primary spontaneous pneumothorax.

View all citing articles on Scopus

: Manuscript received March 30; revision accepted May 18.

View full text

Chest

Clinical InvestigationsA Limited Axillary Thoracotomy as Primary Treatment for Recurrent Spontaneous Pneumothorax

Section snippets

MATERIALS AND METHODS

RESULTS

DISCUSSION

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Chest

Spontaneous pneumothorax in young subjects

Thorax

Surgical experience in the management of spontaneous pneumothorax 1972–82

Thorax

Spontaneous pneumothorax

J Thorac Cardiovasc Surg

Clinical Investigations
A Limited Axillary Thoracotomy as Primary Treatment for Recurrent Spontaneous Pneumothorax