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Median sternotomy with bilateral bullous resection for unilateral spontaneous pneumothorax, with special reference to operative indications
J
THORAC CARDIOVASC SURG
1988;96:615-20
Median sternotomy with bilateral bullous resection for unilateral spontaneous pneumothorax, with special reference to operative indications Simultaneous bilateral pulmonary operatiOiti were dooe through median sternotomy in 29 patients with unilateral spontaneous pneumothorax, because buDae and blebs of the lung are frequently bilateral. Bullous lesions on the contralateral lung were encountered in eight of 10 patients (80%) in whom no roentgenographic evidence of the additional lesions bad been detected preoperatively. Postoperative examination of percent vital capacity was satisfactory (more than 80%) in 21 of 23 patients foUowed up over a month after operation, and this suggested that simultaneolti bilateral thoracotomy through median sternotomy does not lead to a much greater decrease in postoperative pulmonary function tban does unilateral operation. To determine the indications for this method of treatment, we investigated the frequency of subsequent development of contralateral pneumothorax in 178 patients who initiaUy had unilateral spontaneous pneumothorax. The occurrence rate of contralateral pneumothorax with visible bullae on chest roentgenograms was as high as 60 % and 33.3 % in patients in their teens and in those in their 20s, respectively. In conclusion, therefore, the bilateral operative approach should be considered, especiaUy in teenaged patients with contralateral buDae, in whom the highest contralateral occurrence rate of 60 % was found.
Michiaki Ikeda, MD, Akira Uno, MD, Yoshio Yamane, MD, and Noboru Hagiwara, MD,
Iwaki-City, Japan
Because of the tendency of bullous lesions of the lung to be bilateral, 1.2 spontaneous pneumothorax on one side often recurs on the opposite side. In fact, the incidence of bilateral spontaneous pneumothorax at Iwaki-Kyouritsu General Hospital, Iwaki-City, Japan, which includes not only simultaneous episodes but also nonsimultaneous contralateral occurrences, is considerably high (14.4%, 52 of 361 patients with pneumothorax). Among teenaged patients, the highest rate of bilaterality, 40.3%, has been shown (25 of 62 patients). In addition, a postoperative onset of contralateral pneumothorax has been noted in 16 of 85 patients (18.8%) operated on unilaterally and followed up over 3 years thereafter. In view of the relative frequency of bilateral pneumothorax, simul-
From the Department of Respiratory Surgery, Iwaki-Kyouritsu General Hospital, Iwaki-City, Japan. Received for publication Aug. 28, 1987. Accepted for publication March 24, 1988. Address for reprints: Michiaki Ikeda, MD, Department of Respiratory Surgery, Iwaki-Kyouritsu General Hospital, 16 Kuzehara, Mimayamachi, Uchigo, Iwaki-City, Fukushima-prefecture, 973, Japan.
taneous bilateral pulmonary operation is thought to be of great advantage in some patients with unilateral spontaneous pneumothorax who are likely to have subsequent contralateral attacks. The purpose of this paper is to report our experience with simultaneous bilateral thoracotomy for patients with unilateral spontaneous pneumothorax and to evaluate the indications for operation from the viewpoint of the frequency of subsequent contralateral development of the disease. SIMULTANEOUS BILATERAL THORACOTOMY FOR PATIENTS WITH UNILATERAL SPONTANEOUS PNEUMOTHORAX
Patients and methods Simultaneous bilateral pulmonary operation through median sternotomy was performed in 29 patients with unilateral spontaneous pneumothorax during the period from 1980 to 1986 (Table I). The series consisted of I I patients with an initial episode of pneumothorax and 18 with a recurrence. The age distribution of the patients was between 16 and 68 years. On preoperative chest roentgenograms, evidence of contralateral bullous lesions was identified in 19 patients, but was not detected in the remaining 10. All of the patients received one-lung anesthesia with a Robertshaw double-lumen endo-
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Table I. Twenty nine cases of unilateral spontaneous pneumothorax treated by simultaneous bilateral thoracotomy through median sternotomy Detection of contralateral bullae*
Case
I
2 3 4 5 6 7 8 9 IO
II
12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Age (yr)
Sex
19 27 29 19 47 27 42 68 28 18 20 16 18 22 21 21 29 20 26 24 27 17 20 24 19 21 27 15 32
M M M M M M M M M M M M M M M M M M M M M M M M M M M M M
No. of previous episodes
Preoperative chest x-ray film
2 2 I
2 3 3 3 2 2 I
2 2 2 I
2 I I
2 3 I
2 2 I I I
3 I
3 I
+ + + +
Operation
++ ++ + ++ + + ++ +++ ++ + +
+ + + + + ++ + + + ++ + + + + ++
++ + + + + ++ + ++ + + ++ + + + + ++
Intraoperative hemorrhage (ml)
Postoperative hospital stay (days)
400
12 101 22 18 16 12 16 82 21 21 8 20 13 21 18 10 14 24 14 19 14 15 28 22 21 17 14 19 20
331 300 134 527 385 268 270 232 211 255 198 130 184 168 131 110 205 80 125 300 139 65 68 188 114 273 313 163
Postoperative lung function Percent vital capacity]
Postoperative period
96.8 38.8 137 100 71.4 88.6 100 84 69 82 94 94 98 89
26 days 24 days 2 yr 2 yr 2 yr 2 mo 5 mo
92
116 85 109 130 103 61 90 78.2 48.2 94 87 104 104
I mo
26 days I yr I yr 6 mo 8 mo I yr I mo 9 mo 6 mo 4 mo 5 mo 2 mo 24 days 9 mo 7 mo 28 days 5 rno 3 mo 3 mo 6 mo
*+ = slight; ++ = moderate; +++ = marked. tEach shows the best value of percent vital capacity measured after operation. Cases 2, 3, 10, 22, and 25 were examined only within I postoperative month.
bronchial tube and underwent bilateral wedge resection with the use of a GIA surgical stapling device."
Results Bilateral thoracotomy for unilateral spontaneous pneumothorax revealed an apparent area of bullous lesions on the contralateral lung in 8 of 10 patients (80%) who had no evidence of contralateral bullae on preoperative chest roentgenograms. In all patients in this series, the distribution and size of the bullae on the contralateral lung were almost the same as on the affected side. Blood loss at operation ranged from 65 ml to 527 ml with an average of 216 ml. Postoperative *GIA is a registered trademark of United States Surgical Corporation, Norwalk, Conn.
hospital stays were approximately 2 to 3 weeks, with uneventful convalescence in all patients except for two whose hospital stays were exceptionally prolonged because of old age in one and postoperative liverdamage in the other. (In general, hospital stays tend to be a little longer in Japan than elsewhere owing to the health insurance system. Actually, in our hospital, in all of 69 patients with pneumothorax who underwent unilateral operation after 1980, hospital stay ranged from 7 to 57 days, with an average of 18.5 days.) Postoperative examination of percent vital capacity demonstrated satisfactory results with a level greater than 80% in 21 of 23 patients followed up over a month after operation. Furthermore, normal percent vital capacity was attained within 1 month postoperatively in one of five patients examined (case 2, 96.8%). One exception was noted in a
Volume 96 Number 4
Bilateral resection for pneumothorax
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Table ll. Survey by questionnaires on the recurrence of pneumothorax sent to 221 patients with a unilateral initial episode
Age Teens 20s Over 30
Total
No. of patients followed up over 3 year 34 46
~ 178
No. of patients who died during 3-year follow-up period
No. of patients lost during 3-year follow-up period
0 0
7
u.
27*
1
~ 16
'Two of these patients (7.8%) had had contralateral pneumothorax.
patient (case 3) who had a marked impairment of vital capacity (38.8% in percent vital capacity), which was studied on postoperative day 24; however, this was due to pleural thickness from a prolonged period of preoperative hemopneumothorax.
Case report A 19-year-old male patient (case 4) was referred to Iwaki-Kyouritsu General Hospital on Feb. 6, 1981, with a diagnosis of recurrent right spontaneous pneumothorax. He had had an initial episode, about 3 months previously, treated by intercostal tube drainage. On admission to the hospital, he was experiencing shortness of breath and slight chest pain. Chest roentgenograms demonstrated a moderate degree of pneumothorax on the right side and concomitant evidence of bullous lesions of the left lung (Fig. I). Closed chest tube drainage was immediately initiated, but a substantial air leak continued even after 4 days of drainage. Unfortunately, the patient had to take the entrance examination for a university 10 days later. Because it appeared that it would be difficult to do this when the air leak persisted, definitive treatment by operation was immediately necessary. On Feb. 10, 1981, bilateral simultaneous thoracotomy through median sternotomy was performed and a moderate extent of bullous lesions was found at the apical areas of both lungs (Fig. 2). Wedge resections of the bilateral bullae were accomplished with the use of a GIA surgical stapling device, under one-lung anesthesia with a Robertshaw double-lumen endobronchial tube. The total amount of operative hemorrhage was 134 mI. With an uneventful postoperative convalescence, he was able to go to Tokyo on postoperative day 9 to take the entrance examination. A pulmonary function study approximately 2 years after the operation showed nearly normal values: vital capacity 6.33 L, percent vital capacity 137%, forced expiratory volume in 1 second 5.69 L, and percent forced expiratory volume in I second 90%.
Comment. Thus, in the light of our experience, bilateral simultaneous pulmonary operation through median sternotomy does not appear to be an excessive surgical intervention for patients with unilateral pneumothorax, and it does not lead to a much greater
Fig. 1. Preoperative conventional tomogram of chest reveals bullous lesions at apical areas of both lungs (arrowheads).
diminution of postoperative pulmonary function than does unilateral thoracotomy. Therefore, the bilateral approach should be considered for selected patients with unilateral spontaneous pneumothorax. EXPECfED OCCURRENCE RATE OF CONTRALATERAL PNEUMOTHORAX IN PATIENTS HAVING AN INITIAL EPISODE OF UNILATERAL SPONTANEOUS PNEUMOTHORAX
Patients and methods All of 221 patients with unilateral spontaneous pneumothorax who had been admitted at the time of the initial episode to Iwaki-Kyouritsu General Hospital between 1962 and 1983 were retrospectively surveyed by questionnaires on the recurrence of pneumothorax, and 178 patients responded with a minimum follow-up of 3 years (27 had died and 16 could not be found) (Table II). The onset of subsequent contralateral pneumothorax in these patients was examined and the occurrence rate was evaluated by age of the patient to determine the indication for bilateral simultaneous thoracotomy in unilateral spontaneous pneumothorax.
Results (Table III) Of 178 patients with unilateral initial pneumothorax, 26 had subsequent attacks on the opposite lung, with a contralateral occurrence rate of 14.6%. In a group of 38 patients whose chest roentgenograms at the initial episode had demonstrated apparent evidence of contralateral bullae, the frequency of recurrence went up to 28.9% (11 patients). The results of the study by age showed that in the group of teenagers 14 of 34 patients had contralateral pneumothorax, with an occurrence rate of 41.1%, and in those in this age group with roentgenographic evidence of contralateral bullae, the
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The Journal of Thoracic and Cardiovascular Surgery
Fig. 2. Operative findings. A multitude of small and large thin-walled bullae were found on contralateral unaffected lung. highest occurrence rate of 60% was obtained (six of 10 patients). In the group of patients in their 20s, contralateral pneumothorax occurred in seven of 46 patients (15.2%), whereas in those with contralateral bullae, there was a considerably higher occurrence rate of 33.3% (four of 12 patients). In the group of patients 30 and older, in contrast, a low contralateral occurrence rate of 5.1% (five of 98 patients) was noticed, although there was a little rise in the rate (6.2%, one of 16 patients) in those with visible contralateral bullae. From the observations in our series, subsequent contralateral pneumothorax proved to occur most frequently both in patients in their teens and in those in their 20s who had contralateral bullae visible on roentgenogram. Therefore, it is reasonable that bilateral simultaneous operation for unilateral spontaneous pneumothorax should be the treatment of choice for these two groups, especially for the teenaged patients with contralateral bullae, because of the high contralateral occurrence rate in this group of 60%. Discussion Because of the frequently bilateral nature of bullous lesions of the lung, there is a risk of occasional contralateral collapse in patients with unilateral pneumothorax.!" The incidence of bilateral spontaneous pneumothorax, which includes simultaneous episodes and nonsimultaneous contralateral occurrences, has been reported to range from 7.8%3 to 20%2 of the total cases of spontaneous pneumothorax. In our series, the incidence was 14.4% (52 patients) of the 361 cases ofpneumotho-
rax, and particularly in the teenaged group of 62 patients, bilateral pneumothorax accounted for a considerably high rate of 40.3% (25 patients). On the other hand, the unilateral operative procedure itself may often be related to the postoperative contralateral development of the disease.' Driscoll and Aronstam' have reported that postoperative pneumothorax on the contralateral side occurred in 9 of 49 patients (18.3%) operated on. In our series, postoperative contralateral attacks occurred in 16 of 85 patients (18.8%) followed up over 3 years after unilateral operation, and in 21 patients in their teens so treated, the incidence rose to 28.5% (six patients). Furthermore, among 42 patients with bilateral (nonsimultaneous) pneumothorax, 20 (47.6%) had previously had unilateral operation, and 12 of them were obliged to undergo reoperation on the affected side. Ohata and associates" reported that 26 of 31 patients (83%) with contralateral pneumothorax had a history of unilateral operation. In noting that subsequent contralateral development in patients with unilateral pneumothorax is by no means so rare as to be defied, it is considered that, at the time of thoracotomy, additional exploration and resection of contralateral bullae by the most minimal invasionalmost the same as a unilateral procedure-will be of great advantage in selected patients with unilateral spontaneous pneumothorax, because such a procedure helps prevent possiblecollapse of the contralateral lung. On the basis of this consideration, bilateral simultaneous thoracotomy through median sternotomy in the manner described by Iwa, Watanabe, and Fukatani" has been
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Bilateral resection for pneumothorax
October 1988
6 19
Table ill. Occurrence of subsequent contralateral pneumothorax in 178 patients who were admitted to the hospital for an initial unilateral attack and were followed up over 3 years thereafter No. cases of unilateral intial pneumothorax
Age Teens With contralateral 20s With contralateral Over 30 With contralateral Total With contralateral
No. cases of contralateral pneumothorax
34 10 46 12 98 16 178 38
bullae bullae bullae bullae
Occurrence rate of contralateral pneumothorax (%)
14 6 7 4 5 I 26 II
41.1 60 15.2 33.3 5.1 6.2 14.6 28.9
Table IV. Postoperative changes in percent vital capacity studied in patients in their teens and 20s with pneumothorax Operative approach Median sternotomy Postoperative day 6-20 21-30 31-60 61-100 101-200 201-364 365
Axillary approach
Posterolateral approach
% vital capacity
No. of patients
% vital capacity
No. of patients
% vital capacity
No. of patients
71.0 70.7 84.5 94.2 99.7* 99.8* 98.8
5 4 II 6 7 7 9
64.0 73.2 74.8 83.8 82.4* 82.6* 92.6
13 9 9 5 9 7 14
63.3 54.7 75.2 80.7
2 4 6 4
92.8
5
The value given for percent vital capacity is the mean value for the number of patients studied. The series consisted of 24 patients operated on bilaterally through median sternotomy. 41 by unilateral axillary thoracotomy. and 13 by a unilateral posterolateral approach. The results showed the tendency of more rapid improvement of percent vital capacity in bilateral operation through median sternotomy. "The difference between the two groups was significant (p < 0.05).
successfully used in 29 patients with unilateral spontaneous pneumothorax since 1980. We have also held the opinion that the degree of surgical intervention imposed by bilateral thoracotomy in patients with unilateral pneumothorax should not exceed that of a unilateral procedure, because, if a bilateral operation produces more bleeding that necessitates blood transfusion, more frequent complications, and more loss of postoperative pulmonary function than does a unilateral operation, the bilateral procedure as prophylactic therapy would appear to be insignificant. In previous years, simultaneous bilateral thoracotomy was regarded as too major an invasion in itself.' However, in recent years, with the recognition of its safety and potential benefits, this approach has been prevalent for bilateral disease of metastatic lung cancer? and giant emphysematous bullae.v" In our series, in the light of our few intraoperative and postoperative complications, bilateral bullous resection through median ster-
notomy appeared to present almost the same degree of surgical intervention as a unilateral procedure by a posterolateral or axillary approach. The operation has also resulted in a small amount of bleeding with an average lossof 216 mI, although in the early stage of our series a relatively large blood loss amounting to 527 mI but not necessitating transfusion occurred in one patient. There were no serious complications associated with bilateral thoracotomy. Concerning postoperative pulmonary function, Cooper, Nelems, and Peason? described that median sternotomy allowed a more rapid recovery in vital capacity than did the posterolateral approach. Similarly, we'? have also reported, at the 25th Annual Meeting of the Japanese Society of Thoracic Diseases in 1985, that in spontaneous pneumothorax, bilateral operation through median sternotomy has generally brought more rapid restoration of pulmonary function and less diminution of percent vital capacity than unilateral operation by the other two approaches (Table IV). Thus
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The Journal of Thoracic and Cardiovascular
Ikeda et al.
simultaneous bilateral operation through median sternotomy has not been an aggresive therapy for patients with unilateral pneumothorax and has carried no significant loss of postoperative pulmonary function in comparison with unilateral thoracotomy. To determine the indications for this method of treatment, we investigated the occurrence rate of subsequent contralateral pneumothorax in patients with unilateral spontaneous pneumothorax. In the group of patients in their teens and in the group of those in their 20s having roentgenographic evidence of bullae on the opposite lung, this rate was relatively high: 41.1% and 33.3%, respectively. In contrast, in the group aged over 30, a low contralateral occurrence rate of 5.1% was demonstrated. Statistically, the incidence of contralateral pneumothorax in patients in their teens and 20s (26.2%, 21 of 80 patients) was apparently higher than that in those aged over 30 (5.1%, 5 of 98) (p < 0.01). There was also a significant difference in the rate of contralateral occurrence between that of the group of patients with contralateral bullae on roentgenogram (28.9%, 11 of 38 patients) and that of those without them (10.7%, 15 of 140 patients) (p < 0.05). According to these statistical analyses, contralateral pneumothorax appeared to be significantly more frequent in teenage patients and in those in their 20s having contralateral bullae at the initial occurrence. Therefore, it has been concluded that bilateral simultaneous operation for unilateral spontaneous pneumothorax should be applied to these groups, especially to the patients in their teens with roentgenographic evidence of contralateral bullae, in whom the highest contralateral occurrence rate of 60% was found.
Surgery
REFERENCES
1. Baronofsky 10, Warden HG, Kaufman JL, Whatley J. Hanner JM. Bilateral therapy for unilateral spontaneous pneumothorax. J THORAC SURG 1957;34:310-22. 2. Kalnis I, Torda TA, Wright JS. Bilateral simultaneous pleurodesis by median sternotomy for spontaneous pneumothorax. Ann Thorac Surg 1973;15:202-6. 3. Myers JA. Simple spontaneous pneumothorax. Dis Chest 1955;26:420-41. 4. Ohata M, Ida M, Endo H, Nino A, Suzuki H. Sesai Y. The clinical analyses and treatment of bilateral spontaneous pneumothorax. Jpn J Chest Dis 1980;39:83-9. 5. Driscoll PJ, Aronstam EM. Experiences in the management of recurrent spontaneous pneumothorax. J THORAC CARDIOVASC SURG 1961;42:174-8. 6. Iwa T, Watanabe Y, Fukatani G. Simultaneous bilateral operations for bullous emphysema by median sternotomy. J THORAC CARDIOVASC SURG 1981;81:732-7. 7. Meng RL, Jensik RJ, Kittle F. Faber LP. Median sternotomy for synchronous bilateral pulmonary operations. J THORAC CARDIOVASC SURG 1980;80:1-7. 8. Lima 0, Ramos L, Biasi PD, Judice L, Cooper JD. Median sternotomy for bilateral resection of emphysematous bullae. J THORAC CARDIOVASC SURG 1981;82: 892-7. 9. Cooper JD, Nelems JM, Peason FG. Extended indications for median sternotomy in patients requiring pulmonary resection. Ann Thorac Surg 1978;26:413-20. 10. Ikeda M, Uno A, Hagiwara N, Shionozaki H. Bilateral simultaneous thoracotomy for unilateral spontaneous pneumothorax. Third report: eomparative study of postoperative pulmonary function. Jpn J Thorac Dis 1985; 23(suppl):390.
THORAC CARDIOVASC SURG
1988;96:615-20
Median sternotomy with bilateral bullous resection for unilateral spontaneous pneumothorax, with special reference to operative indications Simultaneous bilateral pulmonary operatiOiti were dooe through median sternotomy in 29 patients with unilateral spontaneous pneumothorax, because buDae and blebs of the lung are frequently bilateral. Bullous lesions on the contralateral lung were encountered in eight of 10 patients (80%) in whom no roentgenographic evidence of the additional lesions bad been detected preoperatively. Postoperative examination of percent vital capacity was satisfactory (more than 80%) in 21 of 23 patients foUowed up over a month after operation, and this suggested that simultaneolti bilateral thoracotomy through median sternotomy does not lead to a much greater decrease in postoperative pulmonary function tban does unilateral operation. To determine the indications for this method of treatment, we investigated the frequency of subsequent development of contralateral pneumothorax in 178 patients who initiaUy had unilateral spontaneous pneumothorax. The occurrence rate of contralateral pneumothorax with visible bullae on chest roentgenograms was as high as 60 % and 33.3 % in patients in their teens and in those in their 20s, respectively. In conclusion, therefore, the bilateral operative approach should be considered, especiaUy in teenaged patients with contralateral buDae, in whom the highest contralateral occurrence rate of 60 % was found.
Michiaki Ikeda, MD, Akira Uno, MD, Yoshio Yamane, MD, and Noboru Hagiwara, MD,
Iwaki-City, Japan
Because of the tendency of bullous lesions of the lung to be bilateral, 1.2 spontaneous pneumothorax on one side often recurs on the opposite side. In fact, the incidence of bilateral spontaneous pneumothorax at Iwaki-Kyouritsu General Hospital, Iwaki-City, Japan, which includes not only simultaneous episodes but also nonsimultaneous contralateral occurrences, is considerably high (14.4%, 52 of 361 patients with pneumothorax). Among teenaged patients, the highest rate of bilaterality, 40.3%, has been shown (25 of 62 patients). In addition, a postoperative onset of contralateral pneumothorax has been noted in 16 of 85 patients (18.8%) operated on unilaterally and followed up over 3 years thereafter. In view of the relative frequency of bilateral pneumothorax, simul-
From the Department of Respiratory Surgery, Iwaki-Kyouritsu General Hospital, Iwaki-City, Japan. Received for publication Aug. 28, 1987. Accepted for publication March 24, 1988. Address for reprints: Michiaki Ikeda, MD, Department of Respiratory Surgery, Iwaki-Kyouritsu General Hospital, 16 Kuzehara, Mimayamachi, Uchigo, Iwaki-City, Fukushima-prefecture, 973, Japan.
taneous bilateral pulmonary operation is thought to be of great advantage in some patients with unilateral spontaneous pneumothorax who are likely to have subsequent contralateral attacks. The purpose of this paper is to report our experience with simultaneous bilateral thoracotomy for patients with unilateral spontaneous pneumothorax and to evaluate the indications for operation from the viewpoint of the frequency of subsequent contralateral development of the disease. SIMULTANEOUS BILATERAL THORACOTOMY FOR PATIENTS WITH UNILATERAL SPONTANEOUS PNEUMOTHORAX
Patients and methods Simultaneous bilateral pulmonary operation through median sternotomy was performed in 29 patients with unilateral spontaneous pneumothorax during the period from 1980 to 1986 (Table I). The series consisted of I I patients with an initial episode of pneumothorax and 18 with a recurrence. The age distribution of the patients was between 16 and 68 years. On preoperative chest roentgenograms, evidence of contralateral bullous lesions was identified in 19 patients, but was not detected in the remaining 10. All of the patients received one-lung anesthesia with a Robertshaw double-lumen endo-
615
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The Journal 01 Thoracic and Cardiovascular Surgery
Ikeda et al.
Table I. Twenty nine cases of unilateral spontaneous pneumothorax treated by simultaneous bilateral thoracotomy through median sternotomy Detection of contralateral bullae*
Case
I
2 3 4 5 6 7 8 9 IO
II
12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29
Age (yr)
Sex
19 27 29 19 47 27 42 68 28 18 20 16 18 22 21 21 29 20 26 24 27 17 20 24 19 21 27 15 32
M M M M M M M M M M M M M M M M M M M M M M M M M M M M M
No. of previous episodes
Preoperative chest x-ray film
2 2 I
2 3 3 3 2 2 I
2 2 2 I
2 I I
2 3 I
2 2 I I I
3 I
3 I
+ + + +
Operation
++ ++ + ++ + + ++ +++ ++ + +
+ + + + + ++ + + + ++ + + + + ++
++ + + + + ++ + ++ + + ++ + + + + ++
Intraoperative hemorrhage (ml)
Postoperative hospital stay (days)
400
12 101 22 18 16 12 16 82 21 21 8 20 13 21 18 10 14 24 14 19 14 15 28 22 21 17 14 19 20
331 300 134 527 385 268 270 232 211 255 198 130 184 168 131 110 205 80 125 300 139 65 68 188 114 273 313 163
Postoperative lung function Percent vital capacity]
Postoperative period
96.8 38.8 137 100 71.4 88.6 100 84 69 82 94 94 98 89
26 days 24 days 2 yr 2 yr 2 yr 2 mo 5 mo
92
116 85 109 130 103 61 90 78.2 48.2 94 87 104 104
I mo
26 days I yr I yr 6 mo 8 mo I yr I mo 9 mo 6 mo 4 mo 5 mo 2 mo 24 days 9 mo 7 mo 28 days 5 rno 3 mo 3 mo 6 mo
*+ = slight; ++ = moderate; +++ = marked. tEach shows the best value of percent vital capacity measured after operation. Cases 2, 3, 10, 22, and 25 were examined only within I postoperative month.
bronchial tube and underwent bilateral wedge resection with the use of a GIA surgical stapling device."
Results Bilateral thoracotomy for unilateral spontaneous pneumothorax revealed an apparent area of bullous lesions on the contralateral lung in 8 of 10 patients (80%) who had no evidence of contralateral bullae on preoperative chest roentgenograms. In all patients in this series, the distribution and size of the bullae on the contralateral lung were almost the same as on the affected side. Blood loss at operation ranged from 65 ml to 527 ml with an average of 216 ml. Postoperative *GIA is a registered trademark of United States Surgical Corporation, Norwalk, Conn.
hospital stays were approximately 2 to 3 weeks, with uneventful convalescence in all patients except for two whose hospital stays were exceptionally prolonged because of old age in one and postoperative liverdamage in the other. (In general, hospital stays tend to be a little longer in Japan than elsewhere owing to the health insurance system. Actually, in our hospital, in all of 69 patients with pneumothorax who underwent unilateral operation after 1980, hospital stay ranged from 7 to 57 days, with an average of 18.5 days.) Postoperative examination of percent vital capacity demonstrated satisfactory results with a level greater than 80% in 21 of 23 patients followed up over a month after operation. Furthermore, normal percent vital capacity was attained within 1 month postoperatively in one of five patients examined (case 2, 96.8%). One exception was noted in a
Volume 96 Number 4
Bilateral resection for pneumothorax
October 1988
6 17
Table ll. Survey by questionnaires on the recurrence of pneumothorax sent to 221 patients with a unilateral initial episode
Age Teens 20s Over 30
Total
No. of patients followed up over 3 year 34 46
~ 178
No. of patients who died during 3-year follow-up period
No. of patients lost during 3-year follow-up period
0 0
7
u.
27*
1
~ 16
'Two of these patients (7.8%) had had contralateral pneumothorax.
patient (case 3) who had a marked impairment of vital capacity (38.8% in percent vital capacity), which was studied on postoperative day 24; however, this was due to pleural thickness from a prolonged period of preoperative hemopneumothorax.
Case report A 19-year-old male patient (case 4) was referred to Iwaki-Kyouritsu General Hospital on Feb. 6, 1981, with a diagnosis of recurrent right spontaneous pneumothorax. He had had an initial episode, about 3 months previously, treated by intercostal tube drainage. On admission to the hospital, he was experiencing shortness of breath and slight chest pain. Chest roentgenograms demonstrated a moderate degree of pneumothorax on the right side and concomitant evidence of bullous lesions of the left lung (Fig. I). Closed chest tube drainage was immediately initiated, but a substantial air leak continued even after 4 days of drainage. Unfortunately, the patient had to take the entrance examination for a university 10 days later. Because it appeared that it would be difficult to do this when the air leak persisted, definitive treatment by operation was immediately necessary. On Feb. 10, 1981, bilateral simultaneous thoracotomy through median sternotomy was performed and a moderate extent of bullous lesions was found at the apical areas of both lungs (Fig. 2). Wedge resections of the bilateral bullae were accomplished with the use of a GIA surgical stapling device, under one-lung anesthesia with a Robertshaw double-lumen endobronchial tube. The total amount of operative hemorrhage was 134 mI. With an uneventful postoperative convalescence, he was able to go to Tokyo on postoperative day 9 to take the entrance examination. A pulmonary function study approximately 2 years after the operation showed nearly normal values: vital capacity 6.33 L, percent vital capacity 137%, forced expiratory volume in 1 second 5.69 L, and percent forced expiratory volume in I second 90%.
Comment. Thus, in the light of our experience, bilateral simultaneous pulmonary operation through median sternotomy does not appear to be an excessive surgical intervention for patients with unilateral pneumothorax, and it does not lead to a much greater
Fig. 1. Preoperative conventional tomogram of chest reveals bullous lesions at apical areas of both lungs (arrowheads).
diminution of postoperative pulmonary function than does unilateral thoracotomy. Therefore, the bilateral approach should be considered for selected patients with unilateral spontaneous pneumothorax. EXPECfED OCCURRENCE RATE OF CONTRALATERAL PNEUMOTHORAX IN PATIENTS HAVING AN INITIAL EPISODE OF UNILATERAL SPONTANEOUS PNEUMOTHORAX
Patients and methods All of 221 patients with unilateral spontaneous pneumothorax who had been admitted at the time of the initial episode to Iwaki-Kyouritsu General Hospital between 1962 and 1983 were retrospectively surveyed by questionnaires on the recurrence of pneumothorax, and 178 patients responded with a minimum follow-up of 3 years (27 had died and 16 could not be found) (Table II). The onset of subsequent contralateral pneumothorax in these patients was examined and the occurrence rate was evaluated by age of the patient to determine the indication for bilateral simultaneous thoracotomy in unilateral spontaneous pneumothorax.
Results (Table III) Of 178 patients with unilateral initial pneumothorax, 26 had subsequent attacks on the opposite lung, with a contralateral occurrence rate of 14.6%. In a group of 38 patients whose chest roentgenograms at the initial episode had demonstrated apparent evidence of contralateral bullae, the frequency of recurrence went up to 28.9% (11 patients). The results of the study by age showed that in the group of teenagers 14 of 34 patients had contralateral pneumothorax, with an occurrence rate of 41.1%, and in those in this age group with roentgenographic evidence of contralateral bullae, the
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The Journal of Thoracic and Cardiovascular Surgery
Fig. 2. Operative findings. A multitude of small and large thin-walled bullae were found on contralateral unaffected lung. highest occurrence rate of 60% was obtained (six of 10 patients). In the group of patients in their 20s, contralateral pneumothorax occurred in seven of 46 patients (15.2%), whereas in those with contralateral bullae, there was a considerably higher occurrence rate of 33.3% (four of 12 patients). In the group of patients 30 and older, in contrast, a low contralateral occurrence rate of 5.1% (five of 98 patients) was noticed, although there was a little rise in the rate (6.2%, one of 16 patients) in those with visible contralateral bullae. From the observations in our series, subsequent contralateral pneumothorax proved to occur most frequently both in patients in their teens and in those in their 20s who had contralateral bullae visible on roentgenogram. Therefore, it is reasonable that bilateral simultaneous operation for unilateral spontaneous pneumothorax should be the treatment of choice for these two groups, especially for the teenaged patients with contralateral bullae, because of the high contralateral occurrence rate in this group of 60%. Discussion Because of the frequently bilateral nature of bullous lesions of the lung, there is a risk of occasional contralateral collapse in patients with unilateral pneumothorax.!" The incidence of bilateral spontaneous pneumothorax, which includes simultaneous episodes and nonsimultaneous contralateral occurrences, has been reported to range from 7.8%3 to 20%2 of the total cases of spontaneous pneumothorax. In our series, the incidence was 14.4% (52 patients) of the 361 cases ofpneumotho-
rax, and particularly in the teenaged group of 62 patients, bilateral pneumothorax accounted for a considerably high rate of 40.3% (25 patients). On the other hand, the unilateral operative procedure itself may often be related to the postoperative contralateral development of the disease.' Driscoll and Aronstam' have reported that postoperative pneumothorax on the contralateral side occurred in 9 of 49 patients (18.3%) operated on. In our series, postoperative contralateral attacks occurred in 16 of 85 patients (18.8%) followed up over 3 years after unilateral operation, and in 21 patients in their teens so treated, the incidence rose to 28.5% (six patients). Furthermore, among 42 patients with bilateral (nonsimultaneous) pneumothorax, 20 (47.6%) had previously had unilateral operation, and 12 of them were obliged to undergo reoperation on the affected side. Ohata and associates" reported that 26 of 31 patients (83%) with contralateral pneumothorax had a history of unilateral operation. In noting that subsequent contralateral development in patients with unilateral pneumothorax is by no means so rare as to be defied, it is considered that, at the time of thoracotomy, additional exploration and resection of contralateral bullae by the most minimal invasionalmost the same as a unilateral procedure-will be of great advantage in selected patients with unilateral spontaneous pneumothorax, because such a procedure helps prevent possiblecollapse of the contralateral lung. On the basis of this consideration, bilateral simultaneous thoracotomy through median sternotomy in the manner described by Iwa, Watanabe, and Fukatani" has been
Volume 96 Number 4
Bilateral resection for pneumothorax
October 1988
6 19
Table ill. Occurrence of subsequent contralateral pneumothorax in 178 patients who were admitted to the hospital for an initial unilateral attack and were followed up over 3 years thereafter No. cases of unilateral intial pneumothorax
Age Teens With contralateral 20s With contralateral Over 30 With contralateral Total With contralateral
No. cases of contralateral pneumothorax
34 10 46 12 98 16 178 38
bullae bullae bullae bullae
Occurrence rate of contralateral pneumothorax (%)
14 6 7 4 5 I 26 II
41.1 60 15.2 33.3 5.1 6.2 14.6 28.9
Table IV. Postoperative changes in percent vital capacity studied in patients in their teens and 20s with pneumothorax Operative approach Median sternotomy Postoperative day 6-20 21-30 31-60 61-100 101-200 201-364 365
Axillary approach
Posterolateral approach
% vital capacity
No. of patients
% vital capacity
No. of patients
% vital capacity
No. of patients
71.0 70.7 84.5 94.2 99.7* 99.8* 98.8
5 4 II 6 7 7 9
64.0 73.2 74.8 83.8 82.4* 82.6* 92.6
13 9 9 5 9 7 14
63.3 54.7 75.2 80.7
2 4 6 4
92.8
5
The value given for percent vital capacity is the mean value for the number of patients studied. The series consisted of 24 patients operated on bilaterally through median sternotomy. 41 by unilateral axillary thoracotomy. and 13 by a unilateral posterolateral approach. The results showed the tendency of more rapid improvement of percent vital capacity in bilateral operation through median sternotomy. "The difference between the two groups was significant (p < 0.05).
successfully used in 29 patients with unilateral spontaneous pneumothorax since 1980. We have also held the opinion that the degree of surgical intervention imposed by bilateral thoracotomy in patients with unilateral pneumothorax should not exceed that of a unilateral procedure, because, if a bilateral operation produces more bleeding that necessitates blood transfusion, more frequent complications, and more loss of postoperative pulmonary function than does a unilateral operation, the bilateral procedure as prophylactic therapy would appear to be insignificant. In previous years, simultaneous bilateral thoracotomy was regarded as too major an invasion in itself.' However, in recent years, with the recognition of its safety and potential benefits, this approach has been prevalent for bilateral disease of metastatic lung cancer? and giant emphysematous bullae.v" In our series, in the light of our few intraoperative and postoperative complications, bilateral bullous resection through median ster-
notomy appeared to present almost the same degree of surgical intervention as a unilateral procedure by a posterolateral or axillary approach. The operation has also resulted in a small amount of bleeding with an average lossof 216 mI, although in the early stage of our series a relatively large blood loss amounting to 527 mI but not necessitating transfusion occurred in one patient. There were no serious complications associated with bilateral thoracotomy. Concerning postoperative pulmonary function, Cooper, Nelems, and Peason? described that median sternotomy allowed a more rapid recovery in vital capacity than did the posterolateral approach. Similarly, we'? have also reported, at the 25th Annual Meeting of the Japanese Society of Thoracic Diseases in 1985, that in spontaneous pneumothorax, bilateral operation through median sternotomy has generally brought more rapid restoration of pulmonary function and less diminution of percent vital capacity than unilateral operation by the other two approaches (Table IV). Thus
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Ikeda et al.
simultaneous bilateral operation through median sternotomy has not been an aggresive therapy for patients with unilateral pneumothorax and has carried no significant loss of postoperative pulmonary function in comparison with unilateral thoracotomy. To determine the indications for this method of treatment, we investigated the occurrence rate of subsequent contralateral pneumothorax in patients with unilateral spontaneous pneumothorax. In the group of patients in their teens and in the group of those in their 20s having roentgenographic evidence of bullae on the opposite lung, this rate was relatively high: 41.1% and 33.3%, respectively. In contrast, in the group aged over 30, a low contralateral occurrence rate of 5.1% was demonstrated. Statistically, the incidence of contralateral pneumothorax in patients in their teens and 20s (26.2%, 21 of 80 patients) was apparently higher than that in those aged over 30 (5.1%, 5 of 98) (p < 0.01). There was also a significant difference in the rate of contralateral occurrence between that of the group of patients with contralateral bullae on roentgenogram (28.9%, 11 of 38 patients) and that of those without them (10.7%, 15 of 140 patients) (p < 0.05). According to these statistical analyses, contralateral pneumothorax appeared to be significantly more frequent in teenage patients and in those in their 20s having contralateral bullae at the initial occurrence. Therefore, it has been concluded that bilateral simultaneous operation for unilateral spontaneous pneumothorax should be applied to these groups, especially to the patients in their teens with roentgenographic evidence of contralateral bullae, in whom the highest contralateral occurrence rate of 60% was found.
Surgery
REFERENCES
1. Baronofsky 10, Warden HG, Kaufman JL, Whatley J. Hanner JM. Bilateral therapy for unilateral spontaneous pneumothorax. J THORAC SURG 1957;34:310-22. 2. Kalnis I, Torda TA, Wright JS. Bilateral simultaneous pleurodesis by median sternotomy for spontaneous pneumothorax. Ann Thorac Surg 1973;15:202-6. 3. Myers JA. Simple spontaneous pneumothorax. Dis Chest 1955;26:420-41. 4. Ohata M, Ida M, Endo H, Nino A, Suzuki H. Sesai Y. The clinical analyses and treatment of bilateral spontaneous pneumothorax. Jpn J Chest Dis 1980;39:83-9. 5. Driscoll PJ, Aronstam EM. Experiences in the management of recurrent spontaneous pneumothorax. J THORAC CARDIOVASC SURG 1961;42:174-8. 6. Iwa T, Watanabe Y, Fukatani G. Simultaneous bilateral operations for bullous emphysema by median sternotomy. J THORAC CARDIOVASC SURG 1981;81:732-7. 7. Meng RL, Jensik RJ, Kittle F. Faber LP. Median sternotomy for synchronous bilateral pulmonary operations. J THORAC CARDIOVASC SURG 1980;80:1-7. 8. Lima 0, Ramos L, Biasi PD, Judice L, Cooper JD. Median sternotomy for bilateral resection of emphysematous bullae. J THORAC CARDIOVASC SURG 1981;82: 892-7. 9. Cooper JD, Nelems JM, Peason FG. Extended indications for median sternotomy in patients requiring pulmonary resection. Ann Thorac Surg 1978;26:413-20. 10. Ikeda M, Uno A, Hagiwara N, Shionozaki H. Bilateral simultaneous thoracotomy for unilateral spontaneous pneumothorax. Third report: eomparative study of postoperative pulmonary function. Jpn J Thorac Dis 1985; 23(suppl):390.