Bilateral Video-Assisted Thoracoscopic Surgery for Bilateral Spontaneous Pneumothorax

Bilateral Video-Assisted Thoracoscopic Surgery for Bilateral Spontaneous Pneumothorax

minimally invasive technique Bilateral Video-Assisted Thoracoscopic Surgery for Bilateral Spontaneous Pneumothorax* Adel K. Ayed, MD, FCCP Objective:...

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minimally invasive technique Bilateral Video-Assisted Thoracoscopic Surgery for Bilateral Spontaneous Pneumothorax* Adel K. Ayed, MD, FCCP

Objective: To review our experience with bilateral video-assisted thoracoscopic surgery (VATS) for the treatment of bilateral spontaneous pneumothorax (SP). Design: Retrospective study followed by a telephone interview for follow-up. Setting: Thoracic Surgery Department, Chest Diseases Hospital, Kuwait. Patient and interventions: Fifteen patients undergoing bilateral VATS for bilateral SP from 1994 to 1999. Results: The mean age of the patients was 22.9 years (range, 17 to 34 years), and 14 were men. All patients were successfully treated using the bilateral video-assisted technique. Operative indications included simultaneous bilateral pneumothorax (n ⴝ 7) and contralateral recurrence of SP (n ⴝ 8). Twelve patients had primary SP. In the three remaining patients, simultaneous bilateral SP was secondary to sarcoidosis in two patients and histiocytosis X in one patient. Eleven patients had multiple blebs or bullae located in the upper lobes, and 4 patients had no blebs. All blebs or bullae were resected. All patients had gauze pleurodesis. The mean ⴞ SD operative time was 133.6 ⴞ 9.1 min. There were no perioperative complications and no deaths attributable to the procedure. Postoperative prolonged air leak occurred in three patients (20%). The mean drainage time was 3 days (range, 2 to 8 days). The mean postoperative hospital stay was 5 ⴞ 1.7 days. Mean follow-up was 3.3 years (range, 2 to 5 years) for all patients. Pneumothorax recurred in one patient with histiocytosis X after 1 month and required a reoperation on the right side. Conclusions: Bilateral VATS is a safe procedure in the treatment of simultaneous and nonsimultaneous bilateral SP. This avoids the need for subsequent operations. (CHEST 2002; 122:2234 –2237) Key words: pleurodesis; spontaneous pneumothorax; thoracoscopy Abbreviations: SP ⫽ spontaneous pneumothorax; VATS ⫽ video-assisted thoracoscopic surgery

spontaneous pneumothorax (SP) is a R ecurrent disabling disorder that may present either as a

primary pneumothorax in young and otherwise healthy patients or as a secondary pneumothorax because of a complication of an underlying lung disease. In cases of primary SP, there is a tendency of bullous lesions of the lung to be bilateral, so SP on one side often recurs on the opposite side.1 The

*From the Department of Surgery, Faculty of Medicine, Kuwait University, Kuwait. Manuscript received April 25, 2002; revision accepted June 5, 2002. Correspondence to: Adel K. Ayed, MD, FCCP, Department of Surgery, Faculty of Medicine, Kuwait University, PO Box 24923, 13110, Safat, Kuwait; e-mail: [email protected] 2234

incidence of bilateral SP that includes simultaneous episodes and nonsimultaneous contralateral occurrence ranges from 7.8 to 20% of the total cases of SP.1 Studies have suggested video-assisted thoracoscopic surgery (VATS) as a standard approach in the treatment of a recurrent or persistent SP.2–5 In view of the relative frequency of bilateral pneumothorax, simultaneous bilateral VATS is of great advantage in patients with simultaneous bilateral SP or in patients with unilateral SP who have had contralateral attacks before. The aims of this study were to describe our experience in Kuwait and to report on the follow-up of 15 patients with bilateral simultaneous and nonsimultaneous SP treated by bilateral VATS. Minimally Invasive Techniques

Materials and Methods The study was conducted at the Chest Diseases Hospital in Kuwait, which is the only center for the surgical treatment of chest diseases in Kuwait. From December 1994 to December 1999, 15 patients with bilateral simultaneous and nonsimultaneous SP were treated by bilateral VATS. Preoperative investigations included a chest radiograph, CBC count, serum electrolytes, and renal function tests. CT was done in three patients with secondary SP. Operative Technique of VATS While under general anesthesia with a double-lumen endotracheal tube, the patients were placed in the appropriate lateral decubitus position. The patients were prepared and draped as for posterolateral thoracotomy. Single-lung ventilation was started. A 10-mm trocar was introduced through a 1.5-cm skin incision in the eighth intercostal space at midaxillary line for insertion of a 0° videothoracoscope (Karl Storz; Tuttlingen, Germany). Two additional ports were then inserted under direct vision: a 12-mm trocar through the fifth intercostal space on the anterior axillary line, and a 12-mm posterior trocar through the fifth intercostal space near the tip of the scapula. Bullae or blebs were identified and grasped with an empty sponge stick. When no blebs were visible, a small portion of the apex of the lung or a visible lesion was resected. The excision was done by using an endoscopic stapler (ENDO-GIA; Auto-Suture Company, United States Surgical Corporation; Norwalk, CT). Then, a parietal pleural abrasion by gauze was performed. A 28-F chest tube was inserted through the inferior incision in the eighth intercostal space and connected to an underwater seal suction with a negative pressure of 20 cm H2O. Then, the patient was rotated on the opposite lateral decubitus position, and an identical procedure was performed on the contralateral side. Postoperative Care All patients were extubated in the operating room and transferred to the thoracic surgery ward. Antibiotics in the form of cefoxitin were administered to all patients. An IM analgesic,

meperidine, was administered every 4 to 6 h according to patient request, and an oral analgesic (acetaminophen) was administered as needed. The intercostal drain was removed when the underlying lung was fully expanded with no air leakage and ⬍ 100 mL pleural fluid drained through the tube for 24 h. All patients were discharged the day after removal of the chest tube. Postoperative Assessment Data recorded for all patients included the events of pneumothorax, the operative time, and the presence of blebs or bullae. The output and duration of pleural drainage after operation, the amounts of analgesia administered in the first 24 h after the operation, length of hospital stay, postoperative air leak, and recurrence were also recorded. The follow-up chest radiograph was performed at intervals of 1 week, 1 month, and 3 months, and then patients were followed up with a telephone communication. The recurrence was confirmed by chest radiography during the follow-up period. Data are expressed as mean ⫾ SD.

Results The clinical data of the 15 patients with bilateral SP are summarized in Table 1. The mean age at operation was 22.9 ⫾ 4 years (range, 17 to 34 years). The indications for operation are contralateral recurrence of SP in eight patients and simultaneous bilateral SP in seven patients. Twelve patients had primary SP. In the three remaining patients, simultaneous bilateral SP was secondary to sarcoidosis in two patients and histiocytosis X in one patient. The operative time was 134 ⫾ 9 min (range, 120 to 150 min). Subpleural blebs or bullae were present in 11 patients, and they were resected by an endoscopic stapler. In the absence of an identifiable lesion, the apex of the upper lobe or a visible lesion was excised, and this was done in four patients. Pleural abrasion

Table 1—Clinical Data of 15 Patients With SP Treated by Bilateral VATS*

Patient No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Age, yr

Sex

Indication for Surgery

Pathology

34 24 21 20 23 22 24 25 29 21 20 19 25 20 17

Female Male Male Male Male Male Male Male Male Male Male Male Male Male Male

BSP BSP CSP BSP BSP CSP CSP CSP BSP CSP CSP BSP CSP CSP BSP

Sarcoidosis Multiple blebs Multiple blebs Multiple blebs Multiple blebs Multiple blebs Multiple blebs No blebs Sarcoidosis Multiple blebs Multiple blebs Multiple blebs Multiple blebs No blebs Histiocytosis X

Right/Left Postoperative Right/Left Analgesia Operation Pleural Drainage, Chest Tube Hospital Requirement, Time, min mL Duration, d Stay, d mg/24 h Complications 150 145 132 130 130 125 130 130 145 140 120 130 140 120 130

130/80 70/110 100/120 100/170 90/190 160/70 90/70 100/90 150/130 170/130 110/70 190/100 90/110 150/100 75/110

3/6 2/2 3/3 2/3 3/5 4/3 3/3 7/3 3/3 4/3 3/2 5/3 3/3 3/2 3/8

7 3 4 4 6 5 4 8 4 5 4 6 4 4 9

75 150 50 150 150 100 100 50 100 125 100 75 75 100 100

Air leak None None None Pleural effusion None None Air leak None None None Pleural effusion None None Air leak

*BSP ⫽ bilateral SP; CSP ⫽ contralateral SP. www.chestjournal.org

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by gauze was done in all patients. The mean amount of postoperative analgesia in the form of pethidine was 100 ⫾ 32 mg in the first 24 h (range, 50 to 150 mg). Mean duration of chest tube was 3.5 ⫾ 1.6 days (range, 2 to 8 days) on the left side, and 3.4 ⫾ 1.2 days (range 2 to 7 days) on the right side. Three patients (20%) had air leak and required a prolonged pleural drainage for 6 to 8 days, and none required a reoperation. Air leak occurred in two patients with underlying lung disease. Two patients (13%) required pleural drainage for 5 days because of pleural effusion ⬎ 100 mL in 24 h. The postoperative hospital stay ranged from 3 to 9 days (mean, 5 ⫾ 1.7 days). There were no deaths in this series, and no patients required monitoring in the ICU. All patients in this study were followed up regularly (mean follow-up duration, 3.3 years; range, 2 to 5 years). One patient with histiocytosis X had a recurrent ipsilateral pneumothorax on the right side 4 weeks after surgery. This patient underwent a reoperation by thoracotomy; closure of the air leak site and a partial pleurectomy was performed. This patient was then transferred to oncology unit for further management of his disease. The two patients with sarcoidosis had stable disease, and their care were transferred to the respiratory team. No patients had a further recurrence of pneumothorax, and all patients were satisfied with their surgical treatment. In 12 of our patients, no lung disease was apparent during the follow-up period after the occurrence of SP.

Discussion Because of the frequently bilateral nature of bullous lesions of the lung, there is a risk of contralateral pneumothorax in patients with unilateral disease.1 Studies have reported the rate of the first ipsilateral recurrence after first attack to be 21.8 to 45% in patients with primary SP.6 – 8 Contralateral recurrences have been reported in 5 to 15% of patients.1,6,9 However, the risk of contralateral recurrence after unilateral operation have been reported in 18 to 50% of patients.1,2 Furthermore, the risk of contralateral recurrence is higher in patients with radiographic evidence of contralateral bullous disease.1 Ikeda and colleagues1 in 1988 advocated median sternotomy as the ideal radical approach of SP. In their series, 8 of 10 patients had bullous disease found on the contralateral lung, although these were not present on the preoperative chest radiograph. According to those investigators, median sternotomy does not lead to a decrease in postoperative pulmo2236

nary function, as occurs with a unilateral operation, and eliminates the need of staged bilateral operation. Lang-Lazdunski and colleagues10 reported excellent long-term results with single-stage bilateral VATS for bilateral primary SP, or in those requiring radical therapy for the prevention of ipsilateral and contralateral recurrences. Secondary SP is more frequent in patients with simultaneous bilateral SP than in patients with unilateral SP. In the study of Graf-Deuel and Knoblauch,11 the pneumothoraces were secondary to lung disease in 58%. In our series, secondary SP was present in three of seven patients (43%) with simultaneous bilateral SP. The use of small incisions in the VATS procedure has shown a trend toward decreased postoperative analgesia requirements.12 In this series, the mean amount of postoperative analgesia in the form of pethidine was 100 mg in the first 24 h. In a previous study of unilateral VATS, the mean amount was 84 ⫾ 44 mg in the first 24 h.5 Therefore, the analgesia requirements in unilateral and bilateral VATS were comparable. On the basis of this consideration, it appeared worthwhile to propose bilateral VATS approach for selected patients with a bilateral simultaneous SP or a contralateral recurrence of SP. A bilateral VATS approach may avoid the need for subsequent anesthetic and operative procedures, and for additional hospitalizations. We began performing VATS for primary SP in 1994. Good results were obtained with the technique in terms of postoperative pain, short hospital stay, and low recurrence rate. Most series have reported favorable long-term results in patients with primary SP treated by VATS techniques.2–5,12,13 Short-term results from this series were comparable with those reported in the literature for unilateral and bilateral operations.1,4,5,10 The duration of postoperative chest tube drainage ranged from 2 to 8 days (mean, 3 days). Lang-Lazdunski and colleagues10 reported a mean drainage time of 5 days. The postoperative hospital stay is determined mainly by the duration of chest tube insertion. We have reported a short hospital stay (mean, 5 days; range, 3 to 9 days). Our results were comparable with those reported in the literature for unilateral operations.4,5 Passlick and colleagues4 reported a mean hospital stay of 5 days. However, in the study by Lang-Lazdunski et al,10 50% of patients who underwent bilateral operations were discharged home within 7 days because of a different discharge policy. There were no intraoperative or postoperative deaths in this series. The most frequent postoperative complication in this study was prolonged air leak lasting ⬎ 5 days. Three patients (20%) had proMinimally Invasive Techniques

longed air leak. The cause of the air leak problem is either the presence of underlying lung disease, or an air leak on the row of staples or missed bullous areas. Lang-Lazdunski et al10 reported a 16.5% incidence of air leak, and one patient required a reoperation. Waller and colleagues14 found that 18% had prolonged air leak after unilateral VATS for secondary SP. Our long-term recurrence rate is 1 of 15 patients (6.6%). This recurrence occurred within 1 month after the intervention and required a reoperation. The reason for recurrence is the presence of underlying lung disease with multiple cystic lesion. Our recurrence rate is similar to that reported in the literature after thoracoscopy, varying from 3 to 10%.4,5,15–17 The main determinant of prognosis was the presence of underlying lung disease. The prognosis was excellent in the 12 patients with primary SP who had normal lungs or only apical blebs. Pleurodesis can be achieved easily through either apical pleurectomy or gauze pleural abrasion, with a recurrence rate of ⬍ 1% and 1.8 to 6.8%, respectively.3–5,13,15 We used gauze pleurodesis in all patients. In conclusion, the bilateral VATS approach can be done safely in selected patients with bilateral simultaneous and nonsimultaneous SP. The procedure is well tolerated and did not result in major complications. This technique provided excellent long-term results and avoid the need for subsequent operations. References 1 Ikeda M, Uno A, Yamane Y, et al. Median sternotomy with bilateral bullous resection for unilateral spontaneous pneumothorax, with special reference to operative indications. J Thorac Cardiovasc Surg 1988; 96:615– 620 2 Mourox J, Elkaim D, Padovani B, et al. Video-assisted thoracoscopic treatment of spontaneous pneumothorax: technique and results of one hundred cases. J Thorac Cardiovasc Surg 1996; 112:385–391 3 Naunheim KS, Mack MJ, Hazelrigg SR, et al. Safety and

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efficacy of video-assisted thoracic surgical techniques for the treatment of spontaneous pneumothorax. J Thorac Cardiovasc Surg 1995; 109:1198 –1204 Passlick B, Born C, Haussinger K, et al. Efficiency of video-assisted thoracic surgery for primary and secondary spontaneous pneumothorax. Ann Thorac Surg 1998; 65:324 – 327 Ayed AK, Al-Din HJ. The results of thoracoscopic surgery for primary spontaneous pneumothorax. Chest 2000; 118:235– 238 Sadikot RT, Greene T, Meadows K, et al. Recurrence of primary spontaneous pneumothorax. Thorax 1997; 52:805– 809 O’Rourke JP, Yee ES. Civilian spontaneous pneumothorax: treatment options and long-term results. Chest 1989; 96: 1302–1306 Light RW, O’Hara VS, Moritz TE, et al. Intrapleural tetracycline for the prevention of recurrent spontaneous pneumothorax. JAMA 1990; 264:2224 –2230 Baumann MH, Strange C. Treatment of spontaneous pneumothorax: a more aggressive approach? Chest 1997; 112:789 – 804 Lang-Lazdunski LL, Kerangal XD, Pons F, et al. Primary spontaneous pneumothorax: one-stage treatment by bilateral videothoracoscopy. Ann Thorac Surg 2000; 70:412– 417 Graf-Deuel E, Knoblauch A. Simultaneous bilateral spontaneous pneumothorax. Chest 1994; 105:1142–1146 Waller DA, Forty J, Morrit GN. Video-assisted thoracoscopic surgery vs thoracotomy for spontaneous pneumothorax. Ann Thorac Surg 1994; 58:372–377 Bertrand PC, Regnard JF, Spaggiari L, et al. Immediate and long-term results after surgical treatment of primary spontaneous pneumothorax. Ann Thorac Surg 1996; 61:1641–1645 Waller DA, Forty J, Soni AK, et al. Videothoracoscopic operation for secondary spontaneous pneumothorax. Ann Thorac Surg 1994; 57:1612–1615 Inderbitzi RGC, Leiser A, Furrer M, et al. Three years’ experience in video-assisted thoracic surgery (VATS) for spontaneous pneumothorax. J Thorac Cardiovasc Surg 1994; 107:1410 –1415 Hazelrigg SR, Landreneau RJ, Mack M, et al. Thoracoscopic stapled resection for spontaneous pneumothorax. J Thorac Cardiovasc Surg 1993; 105:389 –393 Massard G, Thomas P, Wihlm JM. Minimally invasive management for first and recurrent pneumothorax. Ann Thorac Surg 1998; 66:592–599

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