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J Thorac Cardiovasc Surg 1994;107:1410-1415
© 1994 Mosby, Inc.

GENERAL THORACIC SURGERY

Three years' experience in video-assisted thoracic surgery (VATS) for spontaneous pneumothorax

Rolf G. C. Inderbitzi , MD, Alfred Leiser , MD, Markus Furrer , MD, Ulrich Althaus , MD


Berne, Switzerland

From the Department of Thoracic and Cardiovascular Surgery, University of Berne, Berne, Switzerland.

Received for publication Aug.10, 1993. Accepted for publication Nov. 24, 1993. Address for reprints: R. Inderbitzi, MD, Head of the Department of Surgery, Spital Limmattal, 8952 Schlieren-Zurich, Switzerland.

Abstract

In a prospective study (June 1990 to June 1993), 79 patients were treated for spontaneous pneumothorax by video-assisted thoracoscopic methods with regular follow-up. The observation time was from 3 to 36 months (mean 19.6 months) and was more than 24 months in 27 patients. In 57 patients spontaneous pneumothorax was primary and in 22 secondary. The 53 male and 26 female patients were aged between 17 and 87 years (mean 37 years). Twenty-one patients were treated thoracoscopically for first episode, 22 for persistent pneumothorax (>7 days), and 36 for a recurrence. Endoscopic examination failed to reveal any lung alteration in four patients (5.1%), and treatment then consisted of simple drainage. Leaks were sealed 26 times by means of a Roeder loop with local anesthesia and 14 times by wedge resection with endotracheal anesthesia and one-lung ventilation; 34 patients were treated by pleurectomy. No deaths occurred. Surgical morbidity was 3.8%, and the postoperative complication rate was 5.1%. One patient was excluded from the follow-up study after conversion to a thoracotomy for control of arterial bleeding. We noted six recurrences; four occurred in the first 21 days and three after ligation of the leak with a Roeder loop. We conclude that video-assisted thoracoscopic treatment of spontaneous pneumothorax by wedge resection and pleurectomy has a recurrence-free rate of 93.8% (45/48) and is therefore an effective treatment for all forms of spontaneous pneumothorax. (J THORAC CARDIOVASC SURG 1994;107:1410-5)

To date, the generally accepted treatment strategy for an initial episode of spontaneous pneumothorax has been pleural drainage. If the condition persists, either chemical pleurodesis through the indwelling drain or under thoracoscopic visionGo Go 1-3 or operative therapy isrecommended.Go Go 4-6

In 1989, progress in minimally invasive thoracic surgery led to new therapeutic approaches. Contrary to the well documented method of thoracoscopic pleurodesis for treatment of spontaneous pneumothorax,Go Go Go 1,6-8 video-assisted thoracoscopic methods use basic surgical principles while avoiding thoracotomy.Go Go 9-12 The aim of these surgical techniques is to obtain an accurate diagnosis endoscopically and to selectively treat the underlying pulmonary defect. These techniques include leak closure with a ligature,Go 13 wedgeresection,Go Go Go 10,11,14 and pleurectomy.Go Go 12,15

The recurrence rate of an initial episode of spontaneous pneumothorax is 29% after conservative treatment (observation) and 21% after pleural drainage.Go 7 Over 70% of all relapses occur during the first 2 years.Go 7 Because of this time interval, an initial prospective study to evaluate the role of video-assisted thoracoscopic methods should encompass a period of 2 years. The results should be measured against those of open parietal pleurectomy, which has a long-term recurrence rate less than 5%.Go Go Go 4,16,17 Under this premise, we followed up all patients with spontaneous pneumothorax treated by video-assisted thoracic surgery (VATS) over a 3-year period (June 1990 to June 1993).

PATIENTS AND METHODS

Patients
From June 1990 to June 1993, we treated 79 patients with spontaneous pneumothorax by VATS. All patients were treated according to the algorithm presented in Fig. 1. Seventy-four of the 79 patients (26 female and 53 male patients) were available for follow-up. One patient was excluded from the study after arterial hemorrhage necessitated thoracotomy. Four patients without endoscopically visible lung disease were treated by simple drainage and also excluded. The patients and their general practitioners were interviewed by telephone every 4 months. A radiographic evaluation (posteroanterior and lateral chest x-ray films) was obtained by the patient's general practitioner or in our clinic if one of the following symptoms became manifest: deterioration of the general condition, disablement, respiratory complaints (pain, dyspnea, tachypnea), or any significant chest pains. The observation period extended from June 1990 to June 1993, with an average of 19.6 months (3 to 36 months). The follow-up rate was 97.3%: two patients could not be reached. Three patients died during the study period without a further episode of pneumothorax. The mean age of the patients in our series was 37 years (17 to 87 years). In 22 cases, the patients had frank lung disease: mucoviscidosis in two patients and chronic obstructive pulmonary disease in 20. In the remaining 57 patients idiopathic spontaneous pneumothorax was diagnosed. Twenty-one patients were treated for a first episode, 22 for a persistent spontaneous pneumothorax (drainage lasting longer than 7 days), and 36 patients for a recurrent episode (first to eighth relapse). The pathologic lung lesions that were diagnosed endoscopically were classified according to Vanderschueren's criteriaGo 18 Go(Tables I and GoII). No abnormalities (stage I) were found in four patients with primary spontaneous pneumothorax. Circumscribed adhesions (stage II), most likely caused by previous episodes, could be demonstrated in five patients with spontaneous pneumothorax and in five patients with secondary spontaneous pneumothorax. In the remaining 65 patients (82.3%) endoscopic examination revealed extensive pulmonary changes corresponding to stage III and IV disease: in 17 of 22 patients preexisting pulmonary disease and in 48 of 57 patients idiopathic spontaneous pneumothorax.



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  		Fig. 1. Algorithm for thoracoscopic treatment of 79 patients with spontaneous pneumothorax. DL, Double lung; ev, eventually.

 

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  		Table I. Distribution of pathologic alterations diagnosed by thoracoscopy according to Vanderschueren's classification
 

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  		Table II. Vanderschueren's classificationGo 18 of pneumothorax based onpathologic alterations
 
Operative Technique
Patients with a first episode of spontaneous pneumothorax were placed in the supine position and operated on with a local anesthetic according to the algorithm (Fig. 1). Patients with secondary spontaneous pneumothorax or a relapse were operated on in the lateral position with general anesthesia and one-lung ventilation with a double-lumen tube. The first incision was always placed in the fourth intercostal space at the anterior border of the latissimus dorsi muscle. A 0-degree telescope connected to a video camera was introduced through a 7 mm trocar sleeve. Two further trocars were introduced into the third and fifth intercostal spaces, forming a triangle. All trocars had the same diameter. Instruments and telescopes could be exchanged freely to obtain the best possible exposure. If necessary, carbon dioxide was insufflated to enlarge the spontaneous pneumothorax. The subsequent operation was facilitated by the use of special instruments with tips angled at 25 degrees (Richard Wolf GmbH, Knittlingen, Germany). Circumscribed pulmonary leaks or bullae were grasped at the base together with healthy tissue and ligated with a chromic catgut Roeder loop, ensuring an airtight paren chymal seal. Advanced bullous disease (extensive Vanderschueren stage III or Vanderschueren stage IV disease) was treated by wedge resection with the endoscopic stapler (GIA 30 stapler, Auto Suture Company Division, United States Surgical Corporation, Norwalk, Conn.). One of the incisions was enlarged to fit a 12 mm trocar sleeve so that the stapler could be introduced. After resection or ligation, the lung was ventilated, Ringer's solution was instilled into the pleural cavity, and leaks were sought by dipping progressive lung portions under water.

An endoscopic parietal pleurectomyGo 15 was performed if one of the following criteria was fulfilled: no apparent leak in cases of recurrent or persistent pneumothorax, extensive bullous changes or bullae diffusely embedded in healthy tissue, or presence of generalized pulmonary disease (e.g., mucoviscidosis). The resection border was dependent on the extent of the lung alteration. Normally, this border involved the apical portion of the upper lobe and less frequently the upper margin of the middle or lower lobe. The fifth rib was therefore usually adequate as the caudal limit of the pleurectomy. The basal lung sections vital to ventilation then remained unaffected. The longitudinal limit of the resection ran in an apical direction along the sympathetic trunk to the height of the left subclavian artery or the brachiocephalic trunk on the right side. The pleura was incised at least 1 cm away from the sympathetic trunk to avoid damage by the coagulation hook. Then it was grasped with the parenchyma forceps, raised, and divided with a dissector in the avascular layer of the endothoracic fascia. A T-shaped incision at the height of the large vessels allowed controlled "winglike" dissection in the area of the thoracic inlet without damaging neighboring vessels and nerves. The pleura was removed through the trocar sleeve in three sections. Specimens were routinely sent for histologic examination. After thorough hemostasis and checks for large parenchymal leaks, an air drain and a fluid drain (24F and 28F) were placed through the existing incisions under endoscopic control with a blunt guide. The tips of the drains were placed toward the apex and into the costodiaphragmatic recess. Finally, the pneumothorax was evacuated and the lung reexpanded gently by positive-pressure ventilation. Intrapleural suction was not used, because high negative pressure may damage lung tissue and lead to interstitial pulmonary edema.Go Go 19,20

RESULTS

In 26 patients with primary spontaneous pneumothorax an isolated leak was sealed with a Roeder loop (chromic catgut), and in 14 patients an isolated wedge resection was performed with the GIA 30 stapler. In the remaining 34 patients a parietal pleurectomy was performed, in combination with pulmonary wedge resection or ligature of bullae in 18 of the 34. The duration of the operation, drainage, postoperative hospitalization, and the recurrence rate in relation to the thoracoscopic technique are reported in GoTable III.


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  		Table III. Operating time, postoperative drainage time, duration of postoperative hospitalization, and relapses after thoracoscopically treated spontaneous pneumothorax in 74 patients
 
No intraoperative or postoperative deaths occurred. The intraoperative complication rate was 3.8% (three patients). Asymptomatic sinus bradycardia developed for several minutes in an awake 17-year-old patient, presumably as a result of the instillation of cold Ringer's solution into the thoracic cavity. Intraoperative bleeding occurred in two patients. The third intercostal artery was injured in a 42-year-old man with stage II recurrent pneumothorax and extensive pleural adhesions. Hemorrhage was controlled by monopolar coagulation and thoracoscopic pleurectomy was completed. Diffuse hemorrhage from an atypical branch of the aorta originating below the left subclavian artery occurred in a 46-year-old woman with stage IV disease and extensive adhesions. The hemorrhage was reliably controlled through a transaxillary thoracotomy. Thus the conversion rate to open procedures was 1.3%. No untoward incidents occurred related to anesthesia. No patient required blood products. All patients were extubated on recovering consciousness after the operation. No patient required monitoring in the intensive care unit. Twenty-two patients with persistent spontaneous pneumothorax and chest tubes in place for more than 7 days received perioperative antibiotics. Significant pathologic alterations were found in four postoperative chest x-ray films: an apical, encapsulated hemothorax in the patient with injury to the third intercostal artery; a basal, paracardiac encapsulated hydrothorax in one patient, and basal dystelectasis in two patients. No patient required further therapeutic intervention beyond routine respiratory therapy. Mean time to removal of chest tubes was 46 hours (5 to 240 hours). Patients remained in the hospital for 1 to 20 days after the operation (mean 4.2 days).

The follow-up period was between 3 and 36 months (average 19.6 months) and was longer than 24 months in 27 patients. To date, six patients have had a relapse, four within the first 21 days. With three recurrences, isolated leak ligation done with local anesthesia had the highest failure rate (11.5%); with one relapse, pleurectomy combined with wedge resection or parietal pleurectomy had the lowest (5.6%) (see GoTable III).

DISCUSSION

The term spontaneous pneumothorax can be traced back to the Frenchman Itard, who first described the phenomena of air leak into the pleural space without previous trauma in his dissertation in 1803. Subsequently, a further distinction was established between symptomatic and idiopathic spontaneous pneumothorax. The latter was defined as a pneumothorax in the absence of any lung disease. This term and its synonym primary spontaneous pneumothorax no longer seem adequate. After thorough histologic examination of more than 100 specimens, Masshoff and HöferGo 21 demonstrated in 1973 that subpleural pathomorphologic pulmonary changes were present in many cases of so-called idiopathic or primary spontaneous pneumothorax. The etiology of primary spontaneous pneumothorax is unknown, and several theories have been proposed: elastic fiber defects of the supporting tissueGo 22 or discrepancy between the growth rate of the lungparenchyma and the vascular system.Go 23 In 1991, on thoracoscopic inspection, Boutin, Viallat, and AelonyGo 7 found diffuse, tiny subpleural bullous alterations in many cases of presumably normal lungs in patients with primary spontaneous pneumothorax. In our series, 53 of 57 patients with primary spontaneous pneumothorax had endoscopically visible alterations, which could be treated surgically (see GoTable I). In only four patients did thoracoscopy fail to reveal any lung abnormality. In 24 of 29 patients with primary pneumothorax and in 10 of 14 patients with secondary episodes, extensive and clearly defined changes corresponding to Vanderschueren's stage III and IV were found. These facts underline the diagnostic value of thoracoscopy for spontaneous pneumothorax. Simple chest drainage, a therapy with a recurrence rate of at least 20%,Go 7 cannot be considered satisfactory. VATS should be considered even in patients with a first episode of idiopathic spontaneous pneumothorax. These predominantly young patientsGo 24 may profit most from definitive therapy.

Our analysis of the thoracoscopic techniques reveals the inadequacy of isolated leak ligature with a Roeder loop. Two patients required postoperative drainage for 96 and 120 hours and three others had relapses, leading to a cumulative failure rate of 19.2%. Thus the Roeder sling should be abandoned in favor of wedge resection, a safe and efficient procedure for well-defined lesions.Go Go 10,11 The only patient in our series with recurrence after isolated wedge resection had required drainage for 240 hours after the operation. This strongly suggests that the suture line at the base of the bulla was not placed with a sufficient margin of healthy parenchyma and was therefore not airtight during the first days. Incomplete resection of the diseased portions of lung was almost certainly responsible for the relapse, which occurred 14 months later and which was located immediately beside the old row of staples. Endoscopic pleurectomy fulfills its expections. With only one early recurrence (5.6%) on the fifth postoperative day, it achieved results equal to open pleurectomy (5%).Go Go Go 4,6,17

From the time point and suspected cause of the failures, intraoperative and postoperative complications, and the long-term postoperative period, the following conclusions may be drawn:

  1. In 94.9% of all episodes of spontaneous pneumothorax, the responsible pulmonary changes could be found and managed thoracoscopically. Pathomorphologic changes were observed in 27 of 29 patients (93.1%) with a first episode of so-called idiopathic spontaneous pneumothorax.
  2. VATS wedge resection and parietal pleurectomy, with a success rate of 93.8% (45/48), represents a satisfactory treatment with a therapeutic efficiency comparable with that of open surgical technique. The average postoperative drainage time of 46 hours and the postoperative hospitalization stay (5.1 days) are short.
  3. The recurrences in our series demonstrably resulted from technical errors that may be avoided with increasing operative experience. Isolated leak ligation with a Roeder loop, with its high failure rate (11.5%), was not successful and should be replaced by wedge resection with stapling devices. The algorithm (Fig. 1) may be simplified (Fig. 2), for thoracoscopy failed to reveal pathologic alterations of the lung in only four of 79 patients.
  4. Intraoperative morbidity was 3.9% and postoperative morbidity 5.1%. Serious complications occurred only twice (2.5%) and were caused by hemorrhage, which necessitated no transfusion of blood products in either case.



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  		Fig. 2. Simplified algorithm after evaluation of the results of our patient series. Thoracoscopy with local anesthesia is unnecessary because the Roeder loop (failure rate: 19.2%) has proved to be unsatisfactory andbecause only four of 79 patients had no pleural alterations amenable to surgical intervention.

 
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