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Bilateral bleb excision through median sternotomy
Bilateral Bleb Excision Through Median Sternotomy
Joe F. Neal, MD, Albuquerque,
New Mexico
Gonzalo Vargas, MD, Albuquerque,
New Mexico
Daniel E. Smith, MD, Albuquerque,
New Mexico
Bechara F. Akl, MD, Albuquerque,
New Mexico
W. Sterling Edwards, MD, Albuquerque, New Mexico
Spontaneous pneumothorax is an uncommon disease that occurs in approximately 5 to 15 per 100,000 persons per year. Because of its propensity to occur in young persons and the fact that recurrence is the most common complication [I], it often poses a therapeutic problem that is difficult to resolve. Early in the history of this disease, bed rest was the only therapy available, but as knowledge of the underlying pathophysiology has been more clearly elucidated, a broader spectrum of therapeutic modalities has been employed. Two decades ago operative intervention with resection of subpleural blebs and pleurodesis for recurrence of spontaneous pneumothorax or for persistent air leak became the standard therapy in this country [1,2]. In 1957 Baronofsky et al [3] demonstrated an almost 100 per cent occurrence of bilateral subpleural apical blebs and introduced the concept of simultaneous bilateral treatment for spontaneous pneumothorax. Since that time, there has been only one report of the use of that method. Material and Methods Patients. At the University of New Mexico between September 1973 and July 1978, eleven patients were treated for persistent or recurrent spontaneous pneumothorax. Eight were male and three female. The average age of the patients was 29 years, and the majority were between 17 and 31 years of age; one was 47 and one was 60. Five patients were operated on for recurrent spontaneous pneumothorax (three ipsilateral and two contralateral). Six were operated on for an air leak persistent longer than 5 days; the average duration of the air leak was 8.6 days. One patient with an air leak for 3 days was operated on
From the Department of Surgery, The University of New Mexico School of Medicine, Affiliated Hospitals, Albuquerque, New Mexico. Reprint requests should be addressed to Joe F. Neal, MD, Department of Surgery, Universityof New Mexico School of Medicine, 915 Stanford Drive N.E.. Albuquerque, New Mexico 87131. Presented at the 31st Annual Meeting of the Southwestern Surgical Congress, Las Vegas, Nevada, April 23-26, 1979.
794
because of severe bilateral bullous disease and because prolonged chest tube suction and the possibility of contralateral recurrence were thought to necessitate more aggressive therapy. At surgery bilateral apical subpleural blebs were invariably found. In three patients subpleural blebs were also present in the superior segment of the lower lobe of the right lung. In all of the patients operated on for persistent air leak the site of the leak was identified, and in all except one the site was a ruptured subpleural bleb in the apex of an upper lobe. In the sole exception, a congenital cyst had ruptured, and a bronchopleural fistula persisted. Pneumothorax in this patient persisted despite placement of multiple chest tubes. In all 11 patients there was histologic confirmation of the presence of subpleural emphysematous blebs. The average hospital stay was 12.5 days (range 8 to 18). The time between surgery and discharge averaged 7 days (range 4 to 15). Except for one patient who was in the hospital 15 days postoperatively, all of the others were hospitalized 9 days or less postoperatively, with an average stay of 6.2 days. Complications included one instance of right hemothorax that occurred immediately postoperatively and reyuired the insertion of one additional chest tube and one case of postoperative atelectasis. Otherwise, there were no significant postoperative complications and no wound complications. Follow-up study ranged from 1 to 6 years (average 3.1). Pneumothorax has not recurred in any patient, and all have returned to their preoperative occupations. Operative Technique. A midline incision with longitudinal division of the sternum is made. Both pleural cavities are opened and the specific site of the air leak is identified when possible. Invariably, the apex of the upper lobe of both lungs will be involved with multiple subpleural blebs (Figures 1 to 3). These are grasped with a Duval clamp and elevated into the wound. A mechanical stapling device is applied at the base of these blebs and the apical tissue is excised. The l&g is then forcibly expanded by the anesthesiologist to test for air leak. The process is repeated on the opposite side. The superior segments of the lower lobe of both lungs are inspected. If blebs are present, they are excised. Bilateral abrasion of both the visceral and parietal
The American Journal of Surgery
Bleb Excision Through Sternotomy
Figure 1. Gross specimen of a subpleural bulla typical of those associated with pneumothorax.
Figure 2. Low power mkrograph a of typical but/a associated with pneumothorax. Note tfte “trnot” protifof erative mesotheiium en the visceral pleural surface (hematoxylk and eosin stain; magnification X40, reduced 30 per cent).
Figure 3. Medium power micrograph of a bulla wftfr the polnt of communication between the bulla and the underlying alveoli. Mote the pleural surface upper in right comer (hematoxyltn and stak; eosin magnffkatkn X 160, reduced 30 per cent). Volume 138, December 1979
795
Neal et al
pleurae is accomplished with a dry lap sponge. A chest tube is placed in each hemithorax and the sternum is approximated with circumsternal wires. If possible, the patient is extubated in the operating room and is encouraged to breathe deeply and to cough immediately on arrival in the
recovery room. The patient is ambulated the evening of surgery and the chest tubes are usually removed the 1st day postoperatively. Comments
The indications for operative treatment of spontaneous pneumothorax have been well delineated by several investigators over the past 2 decades. They are predicated on the fact that if treated conservatively, that is, by observation, bed rest, thoracentesis, or all three, there will be a 10 to 60 per cent recurrence rate on the ipsilateral side [1,2] and a 10 to 15 per cent recurrence rate on the contralateral side [2,5]. Ipsilateral recurrence is essentially nil after open thoracotomy with resection of blebs and pleural abrasion [l-8]. Thus, operative indications include recurrence on either the ipsilateral or the contralatera1 side, bilateral pneumothorax (an incidence of 5 per cent), spontaneous pneumothorax associated with giant bullous emphysema or a remote place of residence. Although the operative indications are clear-cut, the choice of operative method is less clear. The accepted approach in this country is unilateral thoracotomy with resection of apical blebs and pleural abrasion to stimulate subsequent pleurodesis. Two factors led us to adopt median sternotomy with bilateral bleb resection and pleural abrasion or pleurectomy as the treatment of choice for this disease. Several investigators demonstrated that spontaneous pneumothorax is caused, virtually 100 per cent of the time, by ruptured subpleural blebs [3,6] (Figures 1 and 2). Baronofsky et al [3] advocated a bilateral approach to this condition through bilateral thoracotomy. They were severely criticized because of the magnitude of surgery for what appeared to be prophylaxis in most instances. We agree that simultaneous lateral thoracotomy is a major insult to the constitution of any patient; however, since contralateral recurrence is approximately 15 per cent, the principle of attacking both sites of disease simultaneously is sound. With bilateral giant bullous emphysema, a single operation eliminates the necessity of staged bilateral thoracotomy as reported by Fitzgerald et al [9] and advocated by Thomas et al [IO]. If a midline approach is used, it adds little to the operation to open the contralateral pleura and effect total correction at one operation. We believe that less pain is associated with median sternotomy than with lateral thoracotomy and 796
therefore that immediate postoperative pulmonary function is more favorable. Cooper et al [II] demonstrated significantly better pulmonary function with median sternotomy than with lateral thoracotomy. They measured vital capacity and peak expiratory flow rates at 2,4, and 7 days postoperatively. Both groups showed a 50 per cent reduction in vital capacity and peak flow rates at 2 days. By 4 days postoperatively, the difference in the two groups was statistically significant and at 7 days postoperatively expiratory flow had returned to 80 per cent of the preoperative values for patients with median sternotomy compared with 64 per cent for those with lateral thoracotomy. Vital capacity was 71 per cent of the preoperative value for median sternotomy, whereas it was 58 per cent for those undergoing lateral thoracotomy. In our series one patient was operated on for bilateral giant bullae who had presented with 100 per cent pneumothorax of the left lung. Six years later he presented with a coin lesion in that lung which was resected through a lateral thoracotomy. He emphatically favored median sternotomy because of less postoperative pain. Summary
We believe that when the indications for operation for spontaneous pneumothorax are met, the procedure of choice is bilateral resection of apical blebs and pleural abrasion through a median sternotomy. This approach allows easy access to both lungs and pleural spaces for a condition that is bilateral 100 per cent of the time. The operative morbidity is minimal and it essentially eliminates both ipsilateral and contralateral recurrence of pneumothorax with an operation that is of lesser rather than greater magnitude. References 1. Gaensler EA: Parietal pleurectomy for recurrent spontaneous pneumothorax. Surg Gynecol Obstet 102: 293, 1956. 2. Gobbel WG, Rhea WG, Nelson IA, Daniel RA: Spontaneous pneumothorax. J Thorac Cardiovasc Surg 46: 331, 1963. 3. Baronofsky ID, Warden HG, Kauffman JL, Whatley J, Hanner JM: Bilateral therapy for unilateral spontaneous pneumothorax. J Thorac Cardiovasc Surg 34: 310, 1957. 4. Kalnins I, Torda TA, Wright JS: Bilateral simultaneous pleurodesis by median sternotomy for spontaneous pneumothorax. Ann Thorac Surg 15: 202, 1973. Levy IF: Spontaneous pneumothorax. Dis Chest 49: 529, 1966. Wilson KS: Spontaneous pneumothorax: a ten-year study. A&lit Med 135: 95, 1970. Seremetis MG: The management of spontaneous pneumothorax. Chest 57: 65, 1970. Saha SP, Arrants JE, Kosa A, Lee WH: Management of spontaneous pneumothorax. Ann Thorac Surg 19: 56 1, 1975. 9. Fitzgerald MS, Keelan PJ. Cugell DW, Gaensler EA: Long term
The American Journal of Surgery
Bleb Excision Through Sternotomy
results of surgery for bullous emphysema. J Thorac Cardiovasc Surg 68: 566, 1974. 10. Thomas P, Storer J, Grierson AL: Bilateral giant pulmonary air cysts. Dis Chest52: 291. 1967. 11. Cooper JD, Nelems JM, Pearson MD: Extended indications for median sternotomy in patients requiring pulmonary resection. Ann Thorac Surg 26: 413, 1978.
Discussion Gilbert S. Campbell (Little Rock, AR): Dr. Neal has modified the concept of bilateral therapy for unilateral spontaneous pneumothorax that was first proposed by Ivan BarcLnofsky at a meeting of the American Association of Thoracic Surgery in 1957 in Chicago. In the discussion that followed Dr. Baronofsky’s presentation, some senior thoracic surgeons stated that obviously no experienced surgeon would repeat this approach and warned the younger surgeons in the audience against the procedure. In Dr. Neal’s presentation, the New Mexico group has used the median sternotomy approach for bilateral excision of blebs and bilateral pleurodesis. Most patients with a small pneumothorax (10 to 15 per cent) require no treatment. A patient with a larger spontaneous pneumothorax should be treated with closed chest tube drainage. The advantages of prompt reexpansion of a collapsed lung are prompt relief of symptoms; avoidance of complications such as chronic pneumothorax, fibrothorax, and empyema; shortened period of hospitalization; and earlier return to economic productivity (Lancet 77: 443,1957). Thoracotomy should be reserved for patients with recurrent or chronic pneumothorax. We prefer parietal pleurectomy over either mechanical or chemical irritation of the pleura and believe that it is the surest way to produce pleural symphysis. The procedure can be performed through an inframammary anterolateral incision carried down through the fifth intercostal space. Before closure of the thoracotomy incision, the third through seventh intercostal nerves can be blocked with Marcaine@ to lessen postoperative discomfort. This procedure produces no permanent alteration in pulmonary function. We do not perform bilateral therapy for unilateral pneumothorax because 85 to 90 per cent of patients with unilateral spontaneous pneumothorax will never have a problem on the contralateral side.
Joseph L. Kovarik (Denver, CO): I am going to have the audacity to disagree not only with the authors but also with the first discusser, Dr. Campbell. I was also at the meeting in Chicago when Dr. Baronofsky was rather roundly chastised. I think that disapproval may be one reason this concept has remained dormant since 1957. I agree with the authors that pleurectomy is unnecessarily radical and is more painful and more bloody than simple dry gauze abrasion. This opinion has been shared by such persons as Brian Blades and Jim Clagget. As for pulmonary function, studies by Genzler and by Beattie and Blades have shown that pulmonary function returns to normal within a year after pleural symphysis. Now why do I disagree with the authors in their bilateral Volume 139, December 1979
approach?
place, most persons who have do not require operation for excision of blebs and pleural symphysis. In our experience, about 60 per cent do not. In the second place, recurrence on the operated side is only 0.4 per cent. At the meeting referred to earlier, Bill Tuttle from Detroit maintained that spontaneous pneumothorax would develop on the unoperated side in only 2 per cent of patients after operation. The authors state it is 10 to 15 per cent. Perhaps the truth lies somewhere in between. However, assuming that this might develop in 10 per cent, all of these patients would not necessarily require an operation for cure; intercostal tube thoracostomy may be sufficient. Over 90 per cent of the patients undergoing a unilateral procedure would not need a second operation. spontaneous
In the
first
pneumothorax
Thomas C. Read (Sun City, AZ): I am presently in Sun City, Arizona, which is in the vicinity of Phoenix, where I have practiced for a number of years. I too am acquainted with the previous modalities described particularly at the meeting of the American Association of Thoracic Surgery. I believe that surgery of such magnitude as thoracotomy or sternal splitting should be a last resort. Dr. Kovarik mentioned some more conservative procedures. I approach the problem first with tube thoracostomy and then, if unsatisfactory, with “poudrage,” an old remedy that invovles installation of various materials into the chest to create a pleural inflammatory reaction that is followed by the pleural symphysis. The chest has received its share of foreign objects; everything but old shoes has been thrown into the chest during various operations in an attempt to create collapse and so forth. I proceeded with the possibility of using poudrage after the use of various materials in malignant pleural effusion; a tube thoracostomy is performed and powder, atabrine, tetracycline, and nitrogen mustard, in the case of malignant effusion, are used. This plan was followed in the treatment of spontaneous pneumothorax and works very well. It deserves a try, as do other conservative measures, before radical surgery is attempted. Joe F. Neal (closing): I would like to address myself to Dr. Kovarik. I would have answered Dr. Campbell in much the same way, citing Blades’s experience with just dry lap sponge abrasion to produce pleurodesis. We believe this is all that is necessary. We have had a little experience with its effectiveness. One patient who was operated on early in our experience showed up 5 years later with a coin lesion in the left side of the chest. We approached it through a lateral thoracotomy and indeed a pleurodesis was effected. We agree that most of these patients will not need an operation. The procedure is only for very specific indications of recurrence or bilaterality, as alluded to in our report. Even if this were a unilateral operation, we would use a midline approach as the superior approach because of the reasons cited in our presentation. At this point, it seems foolish not to take a few extra minutes to open the contralateral side and effect total correction. 797
Joe F. Neal, MD, Albuquerque,
New Mexico
Gonzalo Vargas, MD, Albuquerque,
New Mexico
Daniel E. Smith, MD, Albuquerque,
New Mexico
Bechara F. Akl, MD, Albuquerque,
New Mexico
W. Sterling Edwards, MD, Albuquerque, New Mexico
Spontaneous pneumothorax is an uncommon disease that occurs in approximately 5 to 15 per 100,000 persons per year. Because of its propensity to occur in young persons and the fact that recurrence is the most common complication [I], it often poses a therapeutic problem that is difficult to resolve. Early in the history of this disease, bed rest was the only therapy available, but as knowledge of the underlying pathophysiology has been more clearly elucidated, a broader spectrum of therapeutic modalities has been employed. Two decades ago operative intervention with resection of subpleural blebs and pleurodesis for recurrence of spontaneous pneumothorax or for persistent air leak became the standard therapy in this country [1,2]. In 1957 Baronofsky et al [3] demonstrated an almost 100 per cent occurrence of bilateral subpleural apical blebs and introduced the concept of simultaneous bilateral treatment for spontaneous pneumothorax. Since that time, there has been only one report of the use of that method. Material and Methods Patients. At the University of New Mexico between September 1973 and July 1978, eleven patients were treated for persistent or recurrent spontaneous pneumothorax. Eight were male and three female. The average age of the patients was 29 years, and the majority were between 17 and 31 years of age; one was 47 and one was 60. Five patients were operated on for recurrent spontaneous pneumothorax (three ipsilateral and two contralateral). Six were operated on for an air leak persistent longer than 5 days; the average duration of the air leak was 8.6 days. One patient with an air leak for 3 days was operated on
From the Department of Surgery, The University of New Mexico School of Medicine, Affiliated Hospitals, Albuquerque, New Mexico. Reprint requests should be addressed to Joe F. Neal, MD, Department of Surgery, Universityof New Mexico School of Medicine, 915 Stanford Drive N.E.. Albuquerque, New Mexico 87131. Presented at the 31st Annual Meeting of the Southwestern Surgical Congress, Las Vegas, Nevada, April 23-26, 1979.
794
because of severe bilateral bullous disease and because prolonged chest tube suction and the possibility of contralateral recurrence were thought to necessitate more aggressive therapy. At surgery bilateral apical subpleural blebs were invariably found. In three patients subpleural blebs were also present in the superior segment of the lower lobe of the right lung. In all of the patients operated on for persistent air leak the site of the leak was identified, and in all except one the site was a ruptured subpleural bleb in the apex of an upper lobe. In the sole exception, a congenital cyst had ruptured, and a bronchopleural fistula persisted. Pneumothorax in this patient persisted despite placement of multiple chest tubes. In all 11 patients there was histologic confirmation of the presence of subpleural emphysematous blebs. The average hospital stay was 12.5 days (range 8 to 18). The time between surgery and discharge averaged 7 days (range 4 to 15). Except for one patient who was in the hospital 15 days postoperatively, all of the others were hospitalized 9 days or less postoperatively, with an average stay of 6.2 days. Complications included one instance of right hemothorax that occurred immediately postoperatively and reyuired the insertion of one additional chest tube and one case of postoperative atelectasis. Otherwise, there were no significant postoperative complications and no wound complications. Follow-up study ranged from 1 to 6 years (average 3.1). Pneumothorax has not recurred in any patient, and all have returned to their preoperative occupations. Operative Technique. A midline incision with longitudinal division of the sternum is made. Both pleural cavities are opened and the specific site of the air leak is identified when possible. Invariably, the apex of the upper lobe of both lungs will be involved with multiple subpleural blebs (Figures 1 to 3). These are grasped with a Duval clamp and elevated into the wound. A mechanical stapling device is applied at the base of these blebs and the apical tissue is excised. The l&g is then forcibly expanded by the anesthesiologist to test for air leak. The process is repeated on the opposite side. The superior segments of the lower lobe of both lungs are inspected. If blebs are present, they are excised. Bilateral abrasion of both the visceral and parietal
The American Journal of Surgery
Bleb Excision Through Sternotomy
Figure 1. Gross specimen of a subpleural bulla typical of those associated with pneumothorax.
Figure 2. Low power mkrograph a of typical but/a associated with pneumothorax. Note tfte “trnot” protifof erative mesotheiium en the visceral pleural surface (hematoxylk and eosin stain; magnification X40, reduced 30 per cent).
Figure 3. Medium power micrograph of a bulla wftfr the polnt of communication between the bulla and the underlying alveoli. Mote the pleural surface upper in right comer (hematoxyltn and stak; eosin magnffkatkn X 160, reduced 30 per cent). Volume 138, December 1979
795
Neal et al
pleurae is accomplished with a dry lap sponge. A chest tube is placed in each hemithorax and the sternum is approximated with circumsternal wires. If possible, the patient is extubated in the operating room and is encouraged to breathe deeply and to cough immediately on arrival in the
recovery room. The patient is ambulated the evening of surgery and the chest tubes are usually removed the 1st day postoperatively. Comments
The indications for operative treatment of spontaneous pneumothorax have been well delineated by several investigators over the past 2 decades. They are predicated on the fact that if treated conservatively, that is, by observation, bed rest, thoracentesis, or all three, there will be a 10 to 60 per cent recurrence rate on the ipsilateral side [1,2] and a 10 to 15 per cent recurrence rate on the contralateral side [2,5]. Ipsilateral recurrence is essentially nil after open thoracotomy with resection of blebs and pleural abrasion [l-8]. Thus, operative indications include recurrence on either the ipsilateral or the contralatera1 side, bilateral pneumothorax (an incidence of 5 per cent), spontaneous pneumothorax associated with giant bullous emphysema or a remote place of residence. Although the operative indications are clear-cut, the choice of operative method is less clear. The accepted approach in this country is unilateral thoracotomy with resection of apical blebs and pleural abrasion to stimulate subsequent pleurodesis. Two factors led us to adopt median sternotomy with bilateral bleb resection and pleural abrasion or pleurectomy as the treatment of choice for this disease. Several investigators demonstrated that spontaneous pneumothorax is caused, virtually 100 per cent of the time, by ruptured subpleural blebs [3,6] (Figures 1 and 2). Baronofsky et al [3] advocated a bilateral approach to this condition through bilateral thoracotomy. They were severely criticized because of the magnitude of surgery for what appeared to be prophylaxis in most instances. We agree that simultaneous lateral thoracotomy is a major insult to the constitution of any patient; however, since contralateral recurrence is approximately 15 per cent, the principle of attacking both sites of disease simultaneously is sound. With bilateral giant bullous emphysema, a single operation eliminates the necessity of staged bilateral thoracotomy as reported by Fitzgerald et al [9] and advocated by Thomas et al [IO]. If a midline approach is used, it adds little to the operation to open the contralateral pleura and effect total correction at one operation. We believe that less pain is associated with median sternotomy than with lateral thoracotomy and 796
therefore that immediate postoperative pulmonary function is more favorable. Cooper et al [II] demonstrated significantly better pulmonary function with median sternotomy than with lateral thoracotomy. They measured vital capacity and peak expiratory flow rates at 2,4, and 7 days postoperatively. Both groups showed a 50 per cent reduction in vital capacity and peak flow rates at 2 days. By 4 days postoperatively, the difference in the two groups was statistically significant and at 7 days postoperatively expiratory flow had returned to 80 per cent of the preoperative values for patients with median sternotomy compared with 64 per cent for those with lateral thoracotomy. Vital capacity was 71 per cent of the preoperative value for median sternotomy, whereas it was 58 per cent for those undergoing lateral thoracotomy. In our series one patient was operated on for bilateral giant bullae who had presented with 100 per cent pneumothorax of the left lung. Six years later he presented with a coin lesion in that lung which was resected through a lateral thoracotomy. He emphatically favored median sternotomy because of less postoperative pain. Summary
We believe that when the indications for operation for spontaneous pneumothorax are met, the procedure of choice is bilateral resection of apical blebs and pleural abrasion through a median sternotomy. This approach allows easy access to both lungs and pleural spaces for a condition that is bilateral 100 per cent of the time. The operative morbidity is minimal and it essentially eliminates both ipsilateral and contralateral recurrence of pneumothorax with an operation that is of lesser rather than greater magnitude. References 1. Gaensler EA: Parietal pleurectomy for recurrent spontaneous pneumothorax. Surg Gynecol Obstet 102: 293, 1956. 2. Gobbel WG, Rhea WG, Nelson IA, Daniel RA: Spontaneous pneumothorax. J Thorac Cardiovasc Surg 46: 331, 1963. 3. Baronofsky ID, Warden HG, Kauffman JL, Whatley J, Hanner JM: Bilateral therapy for unilateral spontaneous pneumothorax. J Thorac Cardiovasc Surg 34: 310, 1957. 4. Kalnins I, Torda TA, Wright JS: Bilateral simultaneous pleurodesis by median sternotomy for spontaneous pneumothorax. Ann Thorac Surg 15: 202, 1973. Levy IF: Spontaneous pneumothorax. Dis Chest 49: 529, 1966. Wilson KS: Spontaneous pneumothorax: a ten-year study. A&lit Med 135: 95, 1970. Seremetis MG: The management of spontaneous pneumothorax. Chest 57: 65, 1970. Saha SP, Arrants JE, Kosa A, Lee WH: Management of spontaneous pneumothorax. Ann Thorac Surg 19: 56 1, 1975. 9. Fitzgerald MS, Keelan PJ. Cugell DW, Gaensler EA: Long term
The American Journal of Surgery
Bleb Excision Through Sternotomy
results of surgery for bullous emphysema. J Thorac Cardiovasc Surg 68: 566, 1974. 10. Thomas P, Storer J, Grierson AL: Bilateral giant pulmonary air cysts. Dis Chest52: 291. 1967. 11. Cooper JD, Nelems JM, Pearson MD: Extended indications for median sternotomy in patients requiring pulmonary resection. Ann Thorac Surg 26: 413, 1978.
Discussion Gilbert S. Campbell (Little Rock, AR): Dr. Neal has modified the concept of bilateral therapy for unilateral spontaneous pneumothorax that was first proposed by Ivan BarcLnofsky at a meeting of the American Association of Thoracic Surgery in 1957 in Chicago. In the discussion that followed Dr. Baronofsky’s presentation, some senior thoracic surgeons stated that obviously no experienced surgeon would repeat this approach and warned the younger surgeons in the audience against the procedure. In Dr. Neal’s presentation, the New Mexico group has used the median sternotomy approach for bilateral excision of blebs and bilateral pleurodesis. Most patients with a small pneumothorax (10 to 15 per cent) require no treatment. A patient with a larger spontaneous pneumothorax should be treated with closed chest tube drainage. The advantages of prompt reexpansion of a collapsed lung are prompt relief of symptoms; avoidance of complications such as chronic pneumothorax, fibrothorax, and empyema; shortened period of hospitalization; and earlier return to economic productivity (Lancet 77: 443,1957). Thoracotomy should be reserved for patients with recurrent or chronic pneumothorax. We prefer parietal pleurectomy over either mechanical or chemical irritation of the pleura and believe that it is the surest way to produce pleural symphysis. The procedure can be performed through an inframammary anterolateral incision carried down through the fifth intercostal space. Before closure of the thoracotomy incision, the third through seventh intercostal nerves can be blocked with Marcaine@ to lessen postoperative discomfort. This procedure produces no permanent alteration in pulmonary function. We do not perform bilateral therapy for unilateral pneumothorax because 85 to 90 per cent of patients with unilateral spontaneous pneumothorax will never have a problem on the contralateral side.
Joseph L. Kovarik (Denver, CO): I am going to have the audacity to disagree not only with the authors but also with the first discusser, Dr. Campbell. I was also at the meeting in Chicago when Dr. Baronofsky was rather roundly chastised. I think that disapproval may be one reason this concept has remained dormant since 1957. I agree with the authors that pleurectomy is unnecessarily radical and is more painful and more bloody than simple dry gauze abrasion. This opinion has been shared by such persons as Brian Blades and Jim Clagget. As for pulmonary function, studies by Genzler and by Beattie and Blades have shown that pulmonary function returns to normal within a year after pleural symphysis. Now why do I disagree with the authors in their bilateral Volume 139, December 1979
approach?
place, most persons who have do not require operation for excision of blebs and pleural symphysis. In our experience, about 60 per cent do not. In the second place, recurrence on the operated side is only 0.4 per cent. At the meeting referred to earlier, Bill Tuttle from Detroit maintained that spontaneous pneumothorax would develop on the unoperated side in only 2 per cent of patients after operation. The authors state it is 10 to 15 per cent. Perhaps the truth lies somewhere in between. However, assuming that this might develop in 10 per cent, all of these patients would not necessarily require an operation for cure; intercostal tube thoracostomy may be sufficient. Over 90 per cent of the patients undergoing a unilateral procedure would not need a second operation. spontaneous
In the
first
pneumothorax
Thomas C. Read (Sun City, AZ): I am presently in Sun City, Arizona, which is in the vicinity of Phoenix, where I have practiced for a number of years. I too am acquainted with the previous modalities described particularly at the meeting of the American Association of Thoracic Surgery. I believe that surgery of such magnitude as thoracotomy or sternal splitting should be a last resort. Dr. Kovarik mentioned some more conservative procedures. I approach the problem first with tube thoracostomy and then, if unsatisfactory, with “poudrage,” an old remedy that invovles installation of various materials into the chest to create a pleural inflammatory reaction that is followed by the pleural symphysis. The chest has received its share of foreign objects; everything but old shoes has been thrown into the chest during various operations in an attempt to create collapse and so forth. I proceeded with the possibility of using poudrage after the use of various materials in malignant pleural effusion; a tube thoracostomy is performed and powder, atabrine, tetracycline, and nitrogen mustard, in the case of malignant effusion, are used. This plan was followed in the treatment of spontaneous pneumothorax and works very well. It deserves a try, as do other conservative measures, before radical surgery is attempted. Joe F. Neal (closing): I would like to address myself to Dr. Kovarik. I would have answered Dr. Campbell in much the same way, citing Blades’s experience with just dry lap sponge abrasion to produce pleurodesis. We believe this is all that is necessary. We have had a little experience with its effectiveness. One patient who was operated on early in our experience showed up 5 years later with a coin lesion in the left side of the chest. We approached it through a lateral thoracotomy and indeed a pleurodesis was effected. We agree that most of these patients will not need an operation. The procedure is only for very specific indications of recurrence or bilaterality, as alluded to in our report. Even if this were a unilateral operation, we would use a midline approach as the superior approach because of the reasons cited in our presentation. At this point, it seems foolish not to take a few extra minutes to open the contralateral side and effect total correction. 797