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Cause and Management of Recurrent Primary Spontaneous Pneumothorax After Thoracoscopic Stapler Blebectomy
Original Article
Cause and Management of Recurrent Primary Spontaneous Pneumothorax After Thoracoscopic Stapler Blebectomy Takashi Muramatsu, Mie Shimamura, Motohiko Furuichi, Tatsuhiko Nishii, Shinji Takeshita, Shinichiro Ishimoto, Hiroaki Morooka, Yoko Tanaka, Chiyoshi Yagasaki, Kazumitsu Ohmori and Motomi Shiono, Division of Respiratory Surgery, Department of Surgery, Nihon University School of Medicine, Tokyo, Japan.
BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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. [Asian J Surg 2011;34(2):69–73] Key Words: postoperative pneumothorax recurrence, spontaneous pneumothorax, thoracoscopic stapler blebectomy
Introduction Thoracoscopic stapler blebectomy for spontaneous pneumothorax is minimally invasive, and the period of postoperative hospitalisation is short. It is now becoming a more common procedure than conventional thoracotomy in many institutions.1−5 However, the increase in the number of patients undergoing this operative procedure has led to an unexpectedly high rate of postoperative
recurrence,6−8 thus resulting in numerous difficulties in coping strategies for patients with postoperative recurrence. Only a few case reports of recurrence1−4 have so far been reported; no detailed large-scale studies have yet been reported. Therefore, we retrospectively investigated the causes and management of primary spontaneous pneumothorax recurrence after thoracoscopic stapler blebectomies that our institution performed over the past 14 years.
Address correspondence and reprint requests to Dr Takashi Muramatsu, 30-1 Oyaguchikamimachi, Itabashi-ku, Tokyo 173-8610, Japan. E-mail: [email protected] ● Received: Mar 23, 2010 ● Revised: Dec 24, 2010 ● Accepted: Apr 14, 2011 © 2011 Elsevier. All rights reserved.
ASIAN JOURNAL OF SURGERY VOL 34 • NO 2 • APRIL 2011
69
■ MURAMATSU et al ■
Patients and methods We evaluated 357 patients who presented with primary spontaneous pneumothorax and underwent thoracoscopic stapler blebectomy at Nihon University Itabashi Hospital in Tokyo, Japan from March 1992 to the end of December 2006. Patients with pneumothorax with specific causes such as pulmonary hamartoangiomyomatosis, catamenial pneumothorax, and pneumothorax secondary to chronic obstructive pulmonary disease and patients older than 50 years were excluded. The indications for surgery were a first episode with persistent air leak, a recurrent ipsilateral pneumothorax, or a previous contralateral pneumothorax. There were 312 males and 45 females, and their ages ranged from 12 to 48 years (average, 27.2 years). After being discharged from the hospital, patients received follow-up care at an outpatient clinic at 1 week, 6 months, and 12 months, at which time chest radiography was performed. Approximately 96% of patients received follow-up care for at least 12 months. The mean follow-up was 51.2 months (range, 10–108 months). The patients were instructed to visit a clinic or emergency room whenever they had any symptoms related to the recurrence of pneumothorax, such as chest pain, cough, or dyspnoea. In addition, an interview by telephone was performed before the writing of this article. This study was approved by the ethics committee of the Nihon University School of Medicine. Informed consent was obtained from all subjects participating in the study, and the research procedures were in accordance with the recommendations of the Helsinki Declaration of 1975 and its successive modifications.
either 5 or 10 mm, and the blebs were identified. Thereafter, an intra-operative air-leak test was performed with distilled water. A partial lung resection was performed in the normal lung field, including blebs, with an endoscopic linear stapler. No mechanical or chemical pleurodesis was performed. After coagulating all bleeding points from the trocar insertion holes, a 20-French chest tube was inserted through the trocar insertion hole, and the other trocar insertion holes were then closed with sutures.
Results During surgery, we identified air leaks from blebs using the air-leak test and surgically removed them in 111 patients (31.1%). In 239 patients (66.9%), air leaks from blebs were not identified, but thin, white blebs were seen and surgically removed. In seven patients (2.0%), neither blebs nor air leaks were identified, and we performed blind apical resection.
Age and bilateral pneumothorax occupancy The 30 patients with recurrence after thoracoscopic stapler blebectomy ranged in age from 14 to 40 years (average, 22.4 years) with a gender distribution of 24 males and 6 females; 13 patients had bilateral pneumothorax (43.3%). On the other hand, the 311 patients without postoperative recurrence ranged in age from 12 to 48 years (average, 31.7 years) with a gender distribution of 288 males and 39 females; 32 patients had bilateral pneumothorax (0.98%). A statistically significant difference was observed among the patients with bilateral pneumothorax, and young patients exhibited a higher tendency for postoperative recurrence (Table 1).
Statistical analysis Statistical analyses of the data were performed using the StatView statistical software program 5.0 (SAS Institute, Inc., Cary, NC, USA). Statistical significance was calculated using Cox’s proportional-hazards regression analysis. Statistical significance was defined as p less than 0.05.
Period until recurrence A study of the period from primary thoracoscopic surgery until recurrence in 30 patients showed that the period until recurrence ranged from 14 to 2,136 days (average, 412 days) after surgery, wherein 90.3% of the patients experienced a recurrence within 2 years (Figure 1).
Initial standard thoracoscopic procedure The standard thoracoscopic surgery for spontaneous pneumothorax at our institute was as follows: One-lung ventilation was performed under general anaesthesia. Three trocars (5-mm, 10-mm, and 12-mm) were inserted from the affected side of the thoracic wall. The chest cavity was observed using a thoracoscope with a diameter of
70
Causes of recurrence The causes of recurrence were investigated in 30 patients who underwent initial thoracoscopic stapler bullectomy at our institute; 32 resurgeries were performed on these 30 patients. The causes of recurrence were estimated based on the preoperative computed tomography findings,
ASIAN JOURNAL OF SURGERY VOL 34 • NO 2 •APRIL 2011
■ RECURRENT SP ON STAPLER BLEBECTOMY ■
Table 1. Multivariate analysis: Cox’s proportional hazards regression analysis
Overall
χ2
p
5.712
0.016
Cases
No. of patients (%) 357 (100)
Age Mean (yr) Range Sex Male Female History of pneumothorax Unilateral Bilateral
24.7 12–48 316 (88.5) 41 (11.5)
312 (87.4) 45 (12.6)
0.047
0.828
New bulla New bulla (near staple line) (12 sides) (16 sides)
Unknown (2 sides)
Oversights (2 sides)
Figure 2. The causes of recurrence were investigated in 30 patients. The most common factor was new bulla formation apparently related to the staple line. 7.83
0.005
were conservatively treated with chest drainage only, whereas second surgeries were performed for the remaining 27 sides of 25 patients. In the early stages, four sides (12.5%) were treated by transfer to conventional thoracotomy. However, for the remaining 23 sides (71.9%) of 20 patients, adhesions were separated using improvements in surgical techniques and ultrasonic scalpels, allowing the second surgeries to be performed using only thoracoscopic surgery in the late stages (Figure 4). Therefore, thoracoscopic second surgeries were possible in 23 of 27 (85.2%) sides of 25 patients who underwent second surgeries for thoracoscopic postoperative recurrence at all stages. In all patients who underwent re-operation, we performed additional procedures including pleurodesis.
20 18 16 14 12 Cases
18 16 14 12 10 8 6 4 2 0
10 8 6 4 2 0 ≤6
7–12
13–18 Months
19–24
≥ 25
Figure 1. The interval to collapse from initial stapler bullectomy.
previous intra-operative video findings, previous operative notes, previous postoperative courses, collapsed bulla genesis regions, and intra-operative observations. The most common factor was new bulla formation and occurred in 28 cases, 16 of which were apparently related to the staple line (within 1 cm of the staple line) and 12 of which were not related to the staple line. Two cases were apparent oversights, and the remaining two cases were categorised as “unknown” because the staple lines could not be clearly identified (Figures 2 and 3).
Coping strategies In terms of coping strategies for the 30 patients with thoracoscopic postoperative recurrence, five sides (15.2%)
ASIAN JOURNAL OF SURGERY VOL 34 • NO 2 • APRIL 2011
Discussion Thoracoscopic stapler blebectomy for primary spontaneous pneumothorax spread at a phenomenal rate in the early 1990s, and many institutions replaced conventional thoracotomy with this less invasive surgical method.1−3,9 However, the postoperative recurrence rate for this operative method was higher than expected. While the postoperative recurrence rate of conventional thoracotomy is low,10−12 thoracoscopic stapler blebectomy is associated with a high recurrence rate of approximately 10–20%13−16; therefore, each institution has struggled to implement appropriate measures. A study of patients with postoperative recurrence after thoracoscopic stapler blebectomy showed that many of these patients were young and that patients with histories of bilateral pneumothorax had a significantly higher
71
■ MURAMATSU et al ■
A
B
C
D
Figure 3. Thoracoscopic findings of new bulla formations near the staple lines. The initial staple lines are shown by arrows.
PR for SP (32 sides)
Chest drainage during about a week (32 sides: 100%)
Discharge (5 sides: 15.6%)
Surgery (27 sides: 84.4%) Convert to conventional thoracotomy (4 sides: 12.5%) in early-stage Re-thoracoscopic surgery (23 sides: 71.9%) in late-stage Figure 4. Flow chart of treatment for postoperative recurrence. PR = postoperative recurrence; SP = spontaneous pneumothorax.
72
postoperative recurrence rate. Moreover, our analysis of the causes of recurrence concluded that it was mostly caused by new bullae or blebs near the staple lines. It is necessary to perform appropriate additional procedures at resection stump sites (such as applying absorbable sheets17 or performing abrasion by a laser18,19 or electrocautery9). There are also other reports regarding additional procedures for treating adhesions at the resected sites and the parietal pleura, such as mechanical pleural abrasion20,21 on the parietal pleura, pleurectomy 22,23 of the apical portion of the lung, electroablation,24 and chemical pleurodesis with minocycline25 or talc.6,26,27 However, upon considering both the possibility for a second surgery because of future onsets of malignancy and the aetiology of spontaneous pneumothorax, we believe that it is advisable to take appropriate measures for any resected site of visceral pleura. Regarding resurgery for primary spontaneous pneumothorax, thoracotomy used to be performed for earlystage patients. The degree of adhesion is mild after initial thoracoscopic surgery; thus, most cases are currently able to undergo thoracoscopic resurgery because of technical improvements and the use of ultrasonic scalpels.
ASIAN JOURNAL OF SURGERY VOL 34 • NO 2 •APRIL 2011
■ RECURRENT SP ON STAPLER BLEBECTOMY ■
However, the fact that the degree of adhesion after thoracoscopic surgery is mild may be a causal factor for the high postoperative recurrence rate. In any event, during thoracoscopic surgery for primary spontaneous pneumothorax, it is necessary to take appropriate measures for stump resection sites. It can also be said that thoracoscopic surgery is a less invasive operative method that allows for a second thoracoscopic surgery even after the unfortunate recurrence of spontaneous pneumothorax. Furthermore, if a low recurrence rate after stapler blebectomy is expected, then it is necessary to establish additional procedures for either the visceral or parietal pleura.
References 1. Yim AP, Liu HP. Complications and failures of video-assisted thoracic surgery: experience from two centers in Asia. Ann Thorac Surg 1996;61:538–41. 2. Melvin WS, Krasna MJ, McLaughlin JS. Thoracoscopic management of spontaneous pneumothorax. Chest 1992;102:1877–9. 3. Cannon WB, Vierra MA, Cannon A. Thoracoscopy for spontaneous pneumothorax. Ann Thorac Surg 1993;56:686–7. 4. Cardillo G, Facciolo F, Regal M, et al. Recurrences following videothoracoscopic treatment of primary spontaneous pneumothorax: the role of redo-videothoracoscopy. Eur J Cardiothorac Surg 2001;19:396–9. 5. Hyland MJ, Ashrafi AS, Crepeau A, et al. Is video-assisted thoracoscopic surgery superior to limited axillary thoracotomy in the management of spontaneous pneumothorax? Can Respir J 2001; 8:339–43. 6. Connolly SS, Hurson C, Lynch V. Thoracoscopic management of primary spontaneous pneumothorax. Ir J Med Sci 2002;171: 71–2. 7. de Vos B, Hendriks J, Van Schil P, et al. Long-term results after video-assisted thoracic surgery for spontaneous pneumothorax. Acta Chir Belg 2002;102:439–44. 8. Nakanishi K. Long-term effect of a thoracoscopic stapled bullectomy alone for preventing the recurrence of primary spontaneous pneumothorax. Surg Today 2009;39:553–7. 9. Wakabayashi A. Thoracoscopic ablation of blebs in the treatment of recurrent or persistent spontaneous pneumothorax. Ann Thorac Surg 1989;48:651–3. 10. Simansky DA, Yellin A. Pleural abrasion via axillary thoracotomy in the era of video assisted thoracic surgery. Thorax 1994; 49:922–3. 11. Deslauriers J, Beaulieu M, Despres JP, et al. Transaxillary pleurectomy for treatment of spontaneous pneumothorax. Ann Thorac Surg 1980;30:569–74.
ASIAN JOURNAL OF SURGERY VOL 34 • NO 2 • APRIL 2011
12. Weeden D, Smith GH. Surgical experience in the management of spontaneous pneumothorax, 1972–82. Thorax 1983;38:737–43. 13. Horio H, Nomori H, Fuyuno G, et al. Limited axillary thoracotomy vs video-assisted thoracoscopic surgery for spontaneous pneumothorax. Surg Endosc 1998;12:1155–8. 14. Horio H, Nomori H, Kobayashi R, et al. Impact of additional pleurodesis in video-assisted thoracoscopic bullectomy for primary spontaneous pneumothorax. Surg Endosc 2002;16:630–4. 15. Cheng YJ, Kao EL. Prospective comparison between endosuturing and endostapling in treating primary spontaneous pneumothorax. J Laparoendosc Adv Surg Tech A 2004;14:274–7. 16. Czerny M, Salat A, Fleck T, et al. Lung wedge resection improves outcome in stage I primary spontaneous pneumothorax. Ann Thorac Surg 2004;77:1802–5. 17. Sakamoto K, Takei H, Nishii T, et al. Staple line coverage with absorbable mesh after thoracoscopic bullectomy for spontaneous pneumothorax. Surg Endosc 2004;18:478–81. 18. Sharpe DA, Dixon C, Moghissi K. Thoracoscopic use of laser in intractable pneumothorax. Eur J Cardiothorac Surg 1994;8:34–6. 19. Hazama K, Akashi A, Shigemura N, et al. Less invasive needle thoracoscopic laser ablation of small bullae for primary spontaneous pneumothorax. Eur J Cardiothorac Surg 2003;24:139–44. 20. Casadio C, Rena O, Giobbe R, et al. Stapler blebectomy and pleural abrasion by video-assisted thoracoscopy for spontaneous pneumothorax. J Cardiovasc Surg (Torino) 2002;43:259–62. 21. Cho S, Ryu KM, Jheon S, et al. Additional mechanical pleurodesis after thoracoscopic wedge resection and covering procedure for primary spontaneous pneumothorax. Surg Endosc 2008;23: 986–90. 22. Lang-Lazdunski L, Chapuis O, Bonnet PM, et al. Videothoracoscopic bleb excision and pleural abrasion for the treatment of primary spontaneous pneumothorax: long-term results. Ann Thorac Surg 2003;75:960–5. 23. Wu YC, Chu Y, Liu YH, et al. Thoracoscopic ipsilateral approach to contralateral bullous lesion in patients with bilateral spontaneous pneumothorax. Ann Thorac Surg 2003;76:1665–7; discussion 1667. 24. Sawabata N, Ikeda M, Matsumura A, et al. New electroablation technique following the first-line stapling method for thoracoscopic treatment of primary spontaneous pneumothorax. Chest 2002;121:251–5. 25. Chen JS, Hsu HH, Kuo SW, et al. Effects of additional minocycline pleurodesis after thoracoscopic procedures for primary spontaneous pneumothorax. Chest 2004;125:50–5. 26. Luh SP, Tsai TP, Chou MC, et al. Video-assisted thoracic surgery for spontaneous pneumothorax: outcome of 189 cases. Int Surg 2004;89:185–9. 27. Cardillo G, Carleo F, Giunti R, et al. Videothoracoscopic talc poudrage in primary spontaneous pneumothorax: a singleinstitution experience in 861 cases. J Thorac Cardiovasc Surg 2006;131:322–8.
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Cause and Management of Recurrent Primary Spontaneous Pneumothorax After Thoracoscopic Stapler Blebectomy Takashi Muramatsu, Mie Shimamura, Motohiko Furuichi, Tatsuhiko Nishii, Shinji Takeshita, Shinichiro Ishimoto, Hiroaki Morooka, Yoko Tanaka, Chiyoshi Yagasaki, Kazumitsu Ohmori and Motomi Shiono, Division of Respiratory Surgery, Department of Surgery, Nihon University School of Medicine, Tokyo, Japan.
BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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. [Asian J Surg 2011;34(2):69–73] Key Words: postoperative pneumothorax recurrence, spontaneous pneumothorax, thoracoscopic stapler blebectomy
Introduction Thoracoscopic stapler blebectomy for spontaneous pneumothorax is minimally invasive, and the period of postoperative hospitalisation is short. It is now becoming a more common procedure than conventional thoracotomy in many institutions.1−5 However, the increase in the number of patients undergoing this operative procedure has led to an unexpectedly high rate of postoperative
recurrence,6−8 thus resulting in numerous difficulties in coping strategies for patients with postoperative recurrence. Only a few case reports of recurrence1−4 have so far been reported; no detailed large-scale studies have yet been reported. Therefore, we retrospectively investigated the causes and management of primary spontaneous pneumothorax recurrence after thoracoscopic stapler blebectomies that our institution performed over the past 14 years.
Address correspondence and reprint requests to Dr Takashi Muramatsu, 30-1 Oyaguchikamimachi, Itabashi-ku, Tokyo 173-8610, Japan. E-mail: [email protected] ● Received: Mar 23, 2010 ● Revised: Dec 24, 2010 ● Accepted: Apr 14, 2011 © 2011 Elsevier. All rights reserved.
ASIAN JOURNAL OF SURGERY VOL 34 • NO 2 • APRIL 2011
69
■ MURAMATSU et al ■
Patients and methods We evaluated 357 patients who presented with primary spontaneous pneumothorax and underwent thoracoscopic stapler blebectomy at Nihon University Itabashi Hospital in Tokyo, Japan from March 1992 to the end of December 2006. Patients with pneumothorax with specific causes such as pulmonary hamartoangiomyomatosis, catamenial pneumothorax, and pneumothorax secondary to chronic obstructive pulmonary disease and patients older than 50 years were excluded. The indications for surgery were a first episode with persistent air leak, a recurrent ipsilateral pneumothorax, or a previous contralateral pneumothorax. There were 312 males and 45 females, and their ages ranged from 12 to 48 years (average, 27.2 years). After being discharged from the hospital, patients received follow-up care at an outpatient clinic at 1 week, 6 months, and 12 months, at which time chest radiography was performed. Approximately 96% of patients received follow-up care for at least 12 months. The mean follow-up was 51.2 months (range, 10–108 months). The patients were instructed to visit a clinic or emergency room whenever they had any symptoms related to the recurrence of pneumothorax, such as chest pain, cough, or dyspnoea. In addition, an interview by telephone was performed before the writing of this article. This study was approved by the ethics committee of the Nihon University School of Medicine. Informed consent was obtained from all subjects participating in the study, and the research procedures were in accordance with the recommendations of the Helsinki Declaration of 1975 and its successive modifications.
either 5 or 10 mm, and the blebs were identified. Thereafter, an intra-operative air-leak test was performed with distilled water. A partial lung resection was performed in the normal lung field, including blebs, with an endoscopic linear stapler. No mechanical or chemical pleurodesis was performed. After coagulating all bleeding points from the trocar insertion holes, a 20-French chest tube was inserted through the trocar insertion hole, and the other trocar insertion holes were then closed with sutures.
Results During surgery, we identified air leaks from blebs using the air-leak test and surgically removed them in 111 patients (31.1%). In 239 patients (66.9%), air leaks from blebs were not identified, but thin, white blebs were seen and surgically removed. In seven patients (2.0%), neither blebs nor air leaks were identified, and we performed blind apical resection.
Age and bilateral pneumothorax occupancy The 30 patients with recurrence after thoracoscopic stapler blebectomy ranged in age from 14 to 40 years (average, 22.4 years) with a gender distribution of 24 males and 6 females; 13 patients had bilateral pneumothorax (43.3%). On the other hand, the 311 patients without postoperative recurrence ranged in age from 12 to 48 years (average, 31.7 years) with a gender distribution of 288 males and 39 females; 32 patients had bilateral pneumothorax (0.98%). A statistically significant difference was observed among the patients with bilateral pneumothorax, and young patients exhibited a higher tendency for postoperative recurrence (Table 1).
Statistical analysis Statistical analyses of the data were performed using the StatView statistical software program 5.0 (SAS Institute, Inc., Cary, NC, USA). Statistical significance was calculated using Cox’s proportional-hazards regression analysis. Statistical significance was defined as p less than 0.05.
Period until recurrence A study of the period from primary thoracoscopic surgery until recurrence in 30 patients showed that the period until recurrence ranged from 14 to 2,136 days (average, 412 days) after surgery, wherein 90.3% of the patients experienced a recurrence within 2 years (Figure 1).
Initial standard thoracoscopic procedure The standard thoracoscopic surgery for spontaneous pneumothorax at our institute was as follows: One-lung ventilation was performed under general anaesthesia. Three trocars (5-mm, 10-mm, and 12-mm) were inserted from the affected side of the thoracic wall. The chest cavity was observed using a thoracoscope with a diameter of
70
Causes of recurrence The causes of recurrence were investigated in 30 patients who underwent initial thoracoscopic stapler bullectomy at our institute; 32 resurgeries were performed on these 30 patients. The causes of recurrence were estimated based on the preoperative computed tomography findings,
ASIAN JOURNAL OF SURGERY VOL 34 • NO 2 •APRIL 2011
■ RECURRENT SP ON STAPLER BLEBECTOMY ■
Table 1. Multivariate analysis: Cox’s proportional hazards regression analysis
Overall
χ2
p
5.712
0.016
Cases
No. of patients (%) 357 (100)
Age Mean (yr) Range Sex Male Female History of pneumothorax Unilateral Bilateral
24.7 12–48 316 (88.5) 41 (11.5)
312 (87.4) 45 (12.6)
0.047
0.828
New bulla New bulla (near staple line) (12 sides) (16 sides)
Unknown (2 sides)
Oversights (2 sides)
Figure 2. The causes of recurrence were investigated in 30 patients. The most common factor was new bulla formation apparently related to the staple line. 7.83
0.005
were conservatively treated with chest drainage only, whereas second surgeries were performed for the remaining 27 sides of 25 patients. In the early stages, four sides (12.5%) were treated by transfer to conventional thoracotomy. However, for the remaining 23 sides (71.9%) of 20 patients, adhesions were separated using improvements in surgical techniques and ultrasonic scalpels, allowing the second surgeries to be performed using only thoracoscopic surgery in the late stages (Figure 4). Therefore, thoracoscopic second surgeries were possible in 23 of 27 (85.2%) sides of 25 patients who underwent second surgeries for thoracoscopic postoperative recurrence at all stages. In all patients who underwent re-operation, we performed additional procedures including pleurodesis.
20 18 16 14 12 Cases
18 16 14 12 10 8 6 4 2 0
10 8 6 4 2 0 ≤6
7–12
13–18 Months
19–24
≥ 25
Figure 1. The interval to collapse from initial stapler bullectomy.
previous intra-operative video findings, previous operative notes, previous postoperative courses, collapsed bulla genesis regions, and intra-operative observations. The most common factor was new bulla formation and occurred in 28 cases, 16 of which were apparently related to the staple line (within 1 cm of the staple line) and 12 of which were not related to the staple line. Two cases were apparent oversights, and the remaining two cases were categorised as “unknown” because the staple lines could not be clearly identified (Figures 2 and 3).
Coping strategies In terms of coping strategies for the 30 patients with thoracoscopic postoperative recurrence, five sides (15.2%)
ASIAN JOURNAL OF SURGERY VOL 34 • NO 2 • APRIL 2011
Discussion Thoracoscopic stapler blebectomy for primary spontaneous pneumothorax spread at a phenomenal rate in the early 1990s, and many institutions replaced conventional thoracotomy with this less invasive surgical method.1−3,9 However, the postoperative recurrence rate for this operative method was higher than expected. While the postoperative recurrence rate of conventional thoracotomy is low,10−12 thoracoscopic stapler blebectomy is associated with a high recurrence rate of approximately 10–20%13−16; therefore, each institution has struggled to implement appropriate measures. A study of patients with postoperative recurrence after thoracoscopic stapler blebectomy showed that many of these patients were young and that patients with histories of bilateral pneumothorax had a significantly higher
71
■ MURAMATSU et al ■
A
B
C
D
Figure 3. Thoracoscopic findings of new bulla formations near the staple lines. The initial staple lines are shown by arrows.
PR for SP (32 sides)
Chest drainage during about a week (32 sides: 100%)
Discharge (5 sides: 15.6%)
Surgery (27 sides: 84.4%) Convert to conventional thoracotomy (4 sides: 12.5%) in early-stage Re-thoracoscopic surgery (23 sides: 71.9%) in late-stage Figure 4. Flow chart of treatment for postoperative recurrence. PR = postoperative recurrence; SP = spontaneous pneumothorax.
72
postoperative recurrence rate. Moreover, our analysis of the causes of recurrence concluded that it was mostly caused by new bullae or blebs near the staple lines. It is necessary to perform appropriate additional procedures at resection stump sites (such as applying absorbable sheets17 or performing abrasion by a laser18,19 or electrocautery9). There are also other reports regarding additional procedures for treating adhesions at the resected sites and the parietal pleura, such as mechanical pleural abrasion20,21 on the parietal pleura, pleurectomy 22,23 of the apical portion of the lung, electroablation,24 and chemical pleurodesis with minocycline25 or talc.6,26,27 However, upon considering both the possibility for a second surgery because of future onsets of malignancy and the aetiology of spontaneous pneumothorax, we believe that it is advisable to take appropriate measures for any resected site of visceral pleura. Regarding resurgery for primary spontaneous pneumothorax, thoracotomy used to be performed for earlystage patients. The degree of adhesion is mild after initial thoracoscopic surgery; thus, most cases are currently able to undergo thoracoscopic resurgery because of technical improvements and the use of ultrasonic scalpels.
ASIAN JOURNAL OF SURGERY VOL 34 • NO 2 •APRIL 2011
■ RECURRENT SP ON STAPLER BLEBECTOMY ■
However, the fact that the degree of adhesion after thoracoscopic surgery is mild may be a causal factor for the high postoperative recurrence rate. In any event, during thoracoscopic surgery for primary spontaneous pneumothorax, it is necessary to take appropriate measures for stump resection sites. It can also be said that thoracoscopic surgery is a less invasive operative method that allows for a second thoracoscopic surgery even after the unfortunate recurrence of spontaneous pneumothorax. Furthermore, if a low recurrence rate after stapler blebectomy is expected, then it is necessary to establish additional procedures for either the visceral or parietal pleura.
References 1. Yim AP, Liu HP. Complications and failures of video-assisted thoracic surgery: experience from two centers in Asia. Ann Thorac Surg 1996;61:538–41. 2. Melvin WS, Krasna MJ, McLaughlin JS. Thoracoscopic management of spontaneous pneumothorax. Chest 1992;102:1877–9. 3. Cannon WB, Vierra MA, Cannon A. Thoracoscopy for spontaneous pneumothorax. Ann Thorac Surg 1993;56:686–7. 4. Cardillo G, Facciolo F, Regal M, et al. Recurrences following videothoracoscopic treatment of primary spontaneous pneumothorax: the role of redo-videothoracoscopy. Eur J Cardiothorac Surg 2001;19:396–9. 5. Hyland MJ, Ashrafi AS, Crepeau A, et al. Is video-assisted thoracoscopic surgery superior to limited axillary thoracotomy in the management of spontaneous pneumothorax? Can Respir J 2001; 8:339–43. 6. Connolly SS, Hurson C, Lynch V. Thoracoscopic management of primary spontaneous pneumothorax. Ir J Med Sci 2002;171: 71–2. 7. de Vos B, Hendriks J, Van Schil P, et al. Long-term results after video-assisted thoracic surgery for spontaneous pneumothorax. Acta Chir Belg 2002;102:439–44. 8. Nakanishi K. Long-term effect of a thoracoscopic stapled bullectomy alone for preventing the recurrence of primary spontaneous pneumothorax. Surg Today 2009;39:553–7. 9. Wakabayashi A. Thoracoscopic ablation of blebs in the treatment of recurrent or persistent spontaneous pneumothorax. Ann Thorac Surg 1989;48:651–3. 10. Simansky DA, Yellin A. Pleural abrasion via axillary thoracotomy in the era of video assisted thoracic surgery. Thorax 1994; 49:922–3. 11. Deslauriers J, Beaulieu M, Despres JP, et al. Transaxillary pleurectomy for treatment of spontaneous pneumothorax. Ann Thorac Surg 1980;30:569–74.
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