Thoracoscopic treatment of spontaneous pneumothorax☆
Abstract
In 1973, I tried a new thoracoscopic treatment for the management of spontaneous pneumothorax. Adhesive agents, electrocoagulation, hot air, the neodymium: yttrium-aluminum garnet laser, intrathoracic devices, or various combinations of these have been used in the repair of more than 2,800 cases of ruptured bullae. Today, because the indications are sensitively defined by thoracography, the recurrence rate has decreased to less than 2%.
References (3)
- Y Takeno
Un nouveau traitement du pneumothorax spontané par nébulisation d'une colle liquide sous contrôle thoracoscopique
Bronchopneumologie
(1978)
Cited by (27)
Pleurography (thoracography) for pleural fistulas: A case series
2021, JTCVS TechniquesCitation Excerpt :PG was approved by the Ethical Committee of Nissan Tamagawa Hospital in the 1980s.3
Pleurography (PG) has been described previously but has not gained popularity. PG can determine the exact air leak points in the lung, which is important for treating pneumothorax and pleural fistulas. We believe that the usefulness of PG should be reassessed, and here we describe the method, air leak detection rate, and common complications.
From the 1210 cases of pleural fistulas that were treated at our institution between March 2015 and October 2018, 275 patients with recurrent primary pneumothorax or secondary spontaneous pneumothorax were selected for this study. PG was performed in 127 patients with persistent air leakage during exhalation. In addition, 35 patients with postoperative complications of air leakage persisting for 7 days or longer were included.
Air leak points were detected in 119 patients (73%), in the apex of the lung in 65 cases, in the basal segment in 13 cases, and in the middle lobe or lingular segment in 9 cases. There were 8 cases of hilar lesions, 12 cases of S6 lesions, 8 cases of upper lobe lesions other than apex, and 4 cases of upper mediastinal lesions. Complications within 30 days were observed in 10 cases (6.2%), with 8 grade 2 cases involving fever, 1 grade 3 case involving infection, and one grade 1 case with abdominal distension.
The incidence of grade ≥3 adverse events after PG was 0.6%, which is considered acceptable. Our findings suggest that PG is a safe examination method to identify air leaks before surgery for pleural fistulas.
A new method to detect air leakage in a patient with pneumothorax using saline solution and multidetector-row spiral CT scan
2013, ChestCitation Excerpt :We refer to our new method as “saline-filled CT thoracography.” Aside from contrast thoracography with fluoroscopy10,11 and experimental scintigraphic studies with special radioisotopes,6,12–14 there exist few nonsurgical methods for detecting air leakage. Unfortunately, the use of such techniques is not widespread.
The purpose of this study was to establish a new CT scan method to show signs of air leakage and to detect the point of the lung leak in patients with spontaneous pneumothorax by using saline solution and phonation.
Eleven patients with spontaneous pneumothorax who had a chest tube placed and underwent an operation because of continuing air leakage were studied. After a plain chest CT scan was performed, 0.9% saline was injected into the affected pleural cavity. A CT scan was acquired again while the patient vocalized continuously. The CT images were evaluated by two thoracic surgeons. All patients underwent video-assisted thoracoscopic surgery to confirm their points of leakage and were treated for spontaneous pneumothorax.
Bubble shadows were seen in nine of 11 cases. In seven of those nine cases, multiple bubbles formed foam or wave shadows. These cases had a small pleural fistula. In the other two cases with a large fistula, air-fluid level in bulla and ground-glass attenuation areas were seen in the pulmonary parenchyma. In all 11 cases, some air-leakage signs were seen on CT scan, and a culprit lesion was presumed to exist by analyzing CT imaging findings and confirming with a surgical air-leak test.
With a saline injection and vocalization, CT scan could demonstrate air-leak signs in patients with spontaneous pneumothorax. This method does not require contrast medium, special instruments, or high skill and, thus, is a novel and useful examination to detect the culprit lesion in pneumothorax.
Therapeutic thoracoscopy
1998, Clinics in Chest MedicineThe history of therapeutic thoracoscopy parallels that of diagnostic interventions. Indeed, our ability to treat patients with pleural and pulmonary diseases through small incisions using a rigid telescope attached to a video camera is only limited by our imaginations, access to newer technology, and the need to justify the use of new techniques after comparing their safety and efficacy with time-proven therapies.
Today, therapeutic thoracoscopy encompasses procedures performed by medical and surgical thoracoscopists alike. Many procedures are direct extensions from those used during open chest surgical procedures and readily fall under the umbrella of video-assisted thoracic surgery (VATS). Improved instrumentation, however, has also allowed the experienced and expert nonsurgeon thoracoscopist to expand the spectrum of therapeutic alternatives already available. In this article, turf issues or medical/surgical boundaries are ignored in an attempt to present simply, from the thoracoscopist's perspective, a basic description of the instrumentation, techniques, indications, and complications of therapeutic thoracoscopy as it is performed in the operating room today.
The first therapeutic thoracoscopy was actually performed by Jacobaeus,23 who, in 1921 described a technique of cauterization of pleural pulmonary adhesions during collapse therapy for tuberculosis. Thoracoscopic pleurodesis was performed between 1920 and 1950 in Europe and the United States for recurrent malignant pleural effusions and pneumothorax.60 In the 1940s thoracoscopy was used to evacuate traumatic hemothoraces and detect bleeding. Parietal pleural and intercostal blood vessels could be repaired through small incisions rather than subjecting patients to open thoracotomy.4 Between 1965 and 1990, however, thoracoscopy was virtually ignored in the United States. Additional advances of therapeutic thoracoscopic techniques were made only in Europe, where thoracoscopy continued to be performed by a small number of pleural disease specialists.
Since 1990, thoracoscopy has exploded worldwide. Thoracoscopists were encouraged by the results of therapeutic laparoscopy, advanced videotechnology, and improved endoscopic instrumentation. Initially, instruments designed for laparoscopy were used for chest procedures, but quickly, specially designed instruments and new thoracoscopic strategies were developed. In 1991, the councils of the American Association for Thoracic Surgery and the Society of Thoracic Surgeons appointed a joint committee to develop standards and guidelines pertaining to therapeutic thoracoscopy.53 A few months later, thoracoscopic interventions were a major topic at the First International Congress of Thoracic Endoscopy held in Paris, France.
We performed thoracoscopic wedge resections of blebs with a stapling device under local anesthesia with sedation in 34 consecutive patients who presented with spontaneous pneumothoraces. The indications for surgery included the absence of parietal pleural adhesions and knowledge of the precise bleb location prior to the procedure. Prior to surgery, 0.5% lidocaine was administered into the pleural space, and IV butorphanol tartrate and diazepam were administered to reduce pain and anxiety during the procedure. In our series, the thoracoscopic procedure resulted in favorable outcomes in all but two patients. There was no evidence of hemodynamic instability or arterial blood gas abnormalities encountered during the procedure. Minor postoperative complications were seen in only three patients (two with air leakage and one with transient atelectasis). One patient had a recurrence of his spontaneous pneumothorax 3 months following the procedure. Therefore, the overall success rate was 91%. We compared the results of this therapeutic modality (group 1) with those of 38 patients who underwent the procedure under general anesthesia (group 2) during the same period. The length of hospital stay was shorter in group 1 than in group 2 (4.5±1.3 vs 5.8±1.1 days; p<0.01). Thoracoscopic wedge resections under local anesthesia are safe and offer the benefit of shorter hospital stays. We believe that this thoracoscopic technique will further simplify the surgical treatment of pneumothoraces without incremental risks.
Video-assisted thoracoscopic treatment of spontaneous pneumothorax: Technique and results of one hundred cases
1996, Journal of Thoracic and Cardiovascular SurgeryObjective: This article describes the technique and results for an initial series of 100 pneumothoraces treated by video-assisted thoracoscopy. Methods: From May 1991 to November 1994, 97 patients (78 male and 19 female patients) aged 37.2 ± 17 years (range 14 to 92 years) underwent video-assisted thoracoscopy for treatment of spontaneous pneumothorax (primary in 75 patients, secondary in 22 patients). Results: The procedure was unilateral in 94 patients and bilateral in three patients (total 100 cases). Pleural bullae were resected with an endoscopic linear stapler; a lung biopsy was performed in the absence of any identifiable lesion. Pleurodesis was achieved by electrocoagulation of the pleura ( n = 3), “patch” pleurectomy ( n = 3), subtotal pleurectomy ( n = 20), or pleural abrasion ( n = 74), including conversion to standard thoracotomy in five. One of these five patients had primary pneumothorax and four had secondary pneumothorax. There were no postoperative deaths. A complication developed in 10 patients: five patients with a primary pneumothorax (6.6%) and five with a secondary pneumothorax (27.7%). The mean postoperative hospital stay was 8.25 ± 3.2 days. Mean follow-up is 30 months (range 7 to 49 months). Pneumothorax recurred in 3% of patients, all of whom were operated on at the start of our experience. Three percent of the patients had chronic postoperative chest pain. Conclusions: Video-assisted thoracoscopy is a valid alternative to open thoracotomy for the treatment of spontaneous primary pneumothorax. Its role for the management of secondary pneumothorax remains to be defined. In the long term, the efficacy of video-assisted thoracoscopic pleurodesis and surgeon experience should yield the same results as standard operative therapy. (J T horac Cardiovasc Surg 1996;112:385-91)
Safety and efficacy of video-assisted thoracic surgical techniques for the treatment of spontaneous pneumothorax
1995, The Journal of Thoracic and Cardiovascular SurgeryVideo-assisted thoracic surgery has been widely used in the treatment of spontaneous pneumothorax despite a paucity of data regarding the relative safety and long-term efficacy for this procedure. We reviewed 113 consecutive patients (68 male and 45 female patients, aged 15 to 92 years, mean 35.1) who underwent 121 video-assisted thoracic surgical procedures during 119 hospitalizations from 1991 through 1993. Recurrent ipsilateral pneumothorax was the most frequent indication for surgery and occurred in 77 patients (65%). The most common method of management was stapling of an identified bleb in the lung, which was undertaken in 105 (87%) patients. No operative deaths occurred. Complications included an air leak lasting longer than 5 days in 10 (8%) patients, two of whom required second procedures for definitive management. No episodes of postoperative bleeding or empyema occurred. The postoperative stay ranged from 1 day to 39 days (median 3 days, average 4.3 days) and 99 patients (84%) were discharged within 5 days. Mean follow-up was 13.1 months and ranged from 1 to 34 months. Eleven patients (10%) were lost to follow-up. Ipsilateral pneumothorax recurred after five of 121 procedures (4.1%). Twelve perioperative parameters (age, gender, race, smoking history, site of pneumothorax, severity of pneumothorax, operative indications, number of blebs, site of blebs, bleb ablation, method of pleurodesis, and prolonged postoperative air leak) were entered into univariate and multivariate analysis to identify significant independent predictors of recurrence. The only independent predictor of recurrence was the failure to identify and ablate a bleb at operation, which resulted in a 23% recurrence rate versus a 1.8% rate in those with ablated blebs (p < 0.001). These data suggest that video-assisted thoracic surgery is a viable alternative to thoracotomy for the treatment of recurrent spontaneous pneumothorax. It results in a short hospital stay, low morbidity, high patient acceptance, and a low rate of recurrence. (J THORAC CARDIOVASC SURG 1995;109:1198-204)
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Presented at The First International Symposium on Thoracoscopic Surgery, San Antonio, TX, Jan 22–23, 1993.