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Minimally invasive management for first and recurrent pneumothorax
CURRENT REVIEW
Minimally Invasive Management for First and Recurrent Pneumothorax Gilbert Massard, MD, Pascal Thomas, MD, and Jean-Marie Wihlm, MD Departments of Thoracic Surgery, Hoˆpitaux Universitaires de Strasbourg and Hoˆpital Sainte Marguerite, Marseille, France
Minimally invasive techniques for treatment of pneumothorax should yield the standard of results set with open procedures: the operative morbidity should remain less than 15%, and the recurrence rate less than 1%. In the era before video-assisted thoracic surgery, two minimally invasive variants were used. Chemical pleurodesis resulted in an unsatisfactory recurrence rate of at least 15%. In contrast, pleurectomy and apical stapling performed through a transaxillary minithoracotomy compared favorably with larger thoracotomy approaches, and allowed a reduced hospital stay. Evaluation of videoassisted thoracic surgical operations for spontaneous pneumothorax is hampered by a lack of controlled studies. The general impression is that morbidity did not decline significantly; the main determinant of complications is the patient’s underlying health status. However, published recurrence rates range from 5% to 10%, in spite
of a shorter follow-up time span. Optimized results are achieved when classic principles combining apical wedge resection and pleurodesis are applied. Reduction of hospital stay is not only a result of the new technology, but also changing drainage and discharge policies. Reduction of cost is debatable, because many studies do not consider the cost of video equipment. The main advantage when compared with open thoracotomy is reduction of postoperative pain. The only two available controlled studies conclude that there is no obvious advantage of video-assisted thoracic surgery when compared with conventional limited-access surgery. The future role of video-assisted thoracic surgery in this disease remains to be determined by a large-scale prospective evaluation.
R
of spontaneous pneumothorax, the reader may be misled. Most articles review a patient population including both primary and secondary spontaneous pneumothorax. There is also a varying algorithm of indications for surgical management: the “newborn tool” stimulates surgical activism, and some over-enthusiastic authors advocate aggressive management as soon as the first episode [5]. Over the past 4 years, many articles have been published with the conclusion that VATS has definitely proved itself as the gold standard of treatment for spontaneous pneumothorax. Surprisingly, in the era of evaluation and accreditation, this statement has not been founded on large-scale controlled studies. The present review has been made of the most relevant articles selected by a screening of the Medline database; some historical references have been chosen according to the frequency of citation. Results achieved with open operation have been considered as the standard that should be equalled by less invasive techniques. Early and long-term results of minimally invasive techniques such as chemical pleurodesis, minithoracotomy, and video-assisted surgery are discussed. The potential advantages of video-assisted surgery, in terms of postoperative hospital stay, pain, and eventually cost of treatment, have been critically reviewed.
ecurrent spontaneous pneumothorax is a disabling disorder, which may present either in young and otherwise healthy patients (primary pneumothorax) or as a complication of an underlying lung disease (secondary pneumothorax). Both patient populations should take advantage of the least invasive management preventing further recurrence. Minimally invasive techniques should shorten hospital stay and physical disability, and should lower the cost of treatment, while yielding at least comparable long-term results in comparison with standard open procedures. The recent advent of video-assisted thoracic surgery (VATS) for treatment of spontaneous pneumothorax evolves together with a double paradox. The first paradox is that thoracoscopy has been used during nearly half a century to create artificial pneumothorax as a treatment for tuberculosis [1]! The second paradox is that the concept of minimally invasive surgery, usually presented as a recent innovation, has had its partisans for more than 40 years. Many chest physicians used to perform chemical pleurodesis, either blind or with thoracoscopy, with varying success rates [2, 3]. Pleurectomy via an axillary minithoracotomy, as described in 1976, should be considered a minimally invasive operation, with respect to reduced pain, early discharge, and excellence of the cosmetic result [4]. When going through publications dealing with treatment Address reprint requests to Dr Massard, Department of Thoracic Surgery, Hoˆpitaux Universitaires de Strasbourg, F-67091 Strasbourg, France (email: [email protected]).
© 1998 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
(Ann Thorac Surg 1998;66:592–9) © 1998 by The Society of Thoracic Surgeons
Historical Reference: Surgical Treatment With Thoracotomy Any new treatment modality should compare at least equally well in terms of operative risk and long-term 0003-4975/98/$19.00 PII S0003-4975(98)00621-3
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Table 1. Outcome After Open Operation for Spontaneous Pneumothorax Authors Thomas et al [11] Dumont et al [10] The´venet et al [12] Weeden and Smith [13] Ko¨rner et al [14]
Number
Pleurodesis
107 400 278 233 120
Abrasion Abrasion Pleurectomy Pleurectomy None
Complications (%)
Recurrence (%)
Follow-up (mo)
14 15 6.5 17
0 0.25 1 0.4 5
27 NS 84 56
NS 5 not stated.
results to open thoracotomy, which has set the standard of excellence to be challenged. Classically, the timing of operative intervention should refer to the spontaneous potential of recurrence. Lowest estimates of recurrence after simple chest tube drainage of a first episode range from 10% to 21%; recurrence after a second episode is estimated close to 50%, and close to 80% after a third episode [6, 7]. According to the statistical risk of recurrence, indications for operative intervention have been universally recognized for many years as follows: Second ipsilateral recurrence First contralateral recurrence Bilateral simultaneous pneumothorax Persisting pneumothorax (air leaks beyond day 7 of tube drainage) Spontaneous hemopneumothorax Professions at risk (eg, pilots, scuba divers) Surgical management of pneumothorax has a double objective. Virtually all authors agree that the cause should be treated by resection of blebs, suture of apical perforations, and even blind apical stapling when no obvious lesion has been identified. The second aim of treatment is to create diffuse adhesions to prevent any further recurrence. Long-standing and still unresolved discussion has opposed the proponents of partial or total pleurectomy to the partisans of pleural abrasion [8, 9]. The former believe that pleurectomy is the more efficient treatment, whereas the latter speculate that abrasion preserves the extrapleural plane for a hypothetic and future thoracotomy. Several authors added treatment of the visceral pleura by iodine or silver nitrate [10, 11]. In fine, most published large-scale series show outstanding long-term results with a recurrence rate of less than 1%, regardless of whether the pneumothorax is primary or secondary and whether an abrasion or a pleurectomy has been performed (Table 1) [11–13]. A previous review of the literature, however, demonstrated a slight advantage of pleurectomy over abrasion: the recurrence rate was 0.4% after pleurectomy (n 5 752) and 2.3% after abrasion (n 5 301) [13]. Although the primum movens of spontaneous pneumothorax is a lung disorder, pleurodesis appears to be mandatory: Ko¨rner and colleagues [14] have performed apical wedge resections without pleurodesis through thoracotomy, resulting in a recurrence rate of 5%. The incidence of postoperative complications has been
close to 15% (see Table 1). However, most complications are related to the patient’s status (chronic obstructive pulmonary disease) rather than to the thoracotomy itself. When separating primary and secondary pneumothorax, it appeared that significantly more complications occurred in patients with underlying lung disease: the respective rates were 26.3% for secondary pneumothorax and 7.2% for primary pneumothorax (p , 0.01) [11]. The main complications were hemothorax and prolonged air leaks. Postoperative hemothorax is seen more particularly after pleurectomy, and occurred in 0% to 4% of cases. Total pleurectomy led to an increased complication rate when compared with apical pleurectomy [13]. Prolonged air leaks have been observed in 5% to 10% of patients, and were more frequent in patients with chronic obstructive pulmonary disease [10]. Despite the relatively recent time period reviewed in the work referenced in Table 1, hospital stay was prolonged to a mean of 14 days. This prolonged stay was partially explained by cultural reasons: chest tubes were left in place for 4 to 6 days as a rule, and thoracotomy was thought to require a hospitalization of at least 12 days. Nonetheless, hospital stay was prolonged by 4 days in patients with secondary pneumothorax [11].
“Historic” Alternatives to Thoracotomy In past years, two alternatives to a formal thoracotomy were used: chemical pleurodesis with thoracoscopy under local anesthesia, and apical pleurectomy combined with resection of blebs via a transaxillary minithoracotomy. Both methods may be considered minimally invasive in terms of postoperative pain, shortened hospital stay, and cosmetic result when compared with conventional operations with standard thoracotomy.
Chemical Pleurodesis Chemical pleurodesis has been promoted by chest physicians comfortable with thoracoscopy, thus prolonging the traditions of phtysiology. Instillation of irritating substances into the pleural space should cause local aseptic inflammation leading to dense adhesions. The most popular agents have been talc, tetracycline, and silver nitrate, which share the substantial advantage of a low cost. However, silver nitrate application is particularly painful, and induces a major exudative reaction; therefore, its use has not been reported in recent publications [2]. Injectable tetracycline is no longer commer-
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Table 2. Success Rates With Talc Poudrage for Spontaneous Pneumothorax Authors Gue´rin et al [3] El Khawand et al [18] Van de Brekel et al [19]
Patients
Success Rate
109 200 356
87% 92.7% 88%
cially available; besides, results were not really satisfactory, because the recurrence rate was estimated at 16% in a series of 390 consecutive patients [15]. Talc poudrage has the lowest recurrence rate of all chemical agents [16]. In a comparative trial including 96 patients, the recurrence rate was 36% after simple drainage, 13% after tetracycline pleurodesis, and 8% after talc poudrage [17]. The overall failure rate of talc poudrage is probably higher and may be estimated at 10% to 15% [3, 18, 19] (Table 2). According to Gue´rin and colleagues [3], half of the failures were immediate failures, prompting subsequent thoracotomy. In addition to a relatively high rate of failures, there are several other potential drawbacks of talc poudrage. Fear for asbestos contamination can be excluded reasonably; no single case of mesothelioma has been reported in a survey of 210 patients followed up 14 to 40 years [20]. Further, the threat of restrictive respiratory impairment is apparently unfounded. In a series of 75 patients followed up for 22 to 35 years after talc poudrage, a mild restrictive impairment of lung function (mean total lung capacity, 89% of predicted) was shown [21]. Spirometry showed normal values in 42 patients reviewed by Gue´rin and associates [3]. However, most surgeons favor pleural abrasion or pleurectomy because granuloma formation is considered excessive, and might offer a challenging barrier to any subsequent thoracotomy. In contrast, patchy distribution of talc may fail to prevent recurrences, and may require a subsequent thoracotomy in technically critical conditions. With modern technology, fibrin glue has been tested as a primary treatment for pneumothorax but has shown an unacceptably high recurrence rate of 25% [22]. Therefore, and because of the cost and biologic risks of this material, we do not agree with the statement that fibrin glue might be a valuable alternative to the classic algorithm. The high failure rate of any kind of chemical pleurodesis makes this type of treatment unsuitable for primary spontaneous pneumothorax. Exceptional use of talc poudrage should be restricted to otherwise inoperable patients with secondary pneumothorax.
Transaxillary Minithoracotomy This approach, popularized by Becker and Munro [4] as early as 1976, should by all means be considered a minimally invasive operation in terms of shortness of both incision and hospital stay. The incision is carried at the hairline of the axilla and measures 5 to 6 cm at most; the chest is entered through the third intercostal space. Apical pleurectomy or abrasion is performed, and the apexes of the upper and lower lobe are carefully in-
spected. Blebs or bullae can be drawn to the level of the skin and stapled outside the chest. A single tube is left for 24 hours. A large experience published by Deslauriers and colleagues in 1980 [23] included 362 consecutive patients. Pleurodesis was induced by apical pleurectomy. Four patients required reoperation for bleeding (n 5 3) or air leak (n 5 1), and a further 30 experienced minor complications (9.4%). Mean hospital stay was 6 days. Only 2 patients (0.4%) presented with recurrent pneumothorax. Without any doubt, this straightforward procedure is efficient as far as operating room cost is concerned. Cosmetic results are excellent. Long-term results are optimal. A recent reappraisal by Simansky and Yellin [24] confirmed a reduced hospital stay averaging 4.6 days. However, the recurrence rate among 39 consecutive patients was 4.6% at a mean follow-up of 33 months. The relatively high failure rate could be explained by the fact that bullae were treated with laser coagulation rather than by stapled resection; abrasion was performed instead of pleurectomy to induce pleurodesis.
Overall Results With Video-Assisted Thoracic Surgery To maintain quality at the previously established levels, the fundamental rule of any kind of minimally invasive operation is to perform the same operative procedure as in open surgery, the only difference being the chest wall incision. As expected after the previous debate on pleurodesis, most authors have merely transferred their usual technique to minimally invasive procedure. The largest series published to date favor abrasion [25–27]. Some single series advocate exclusive resection of blebs without pleurodesis [28]. Other authors have changed their technique with growing experience; Inderbitzi and colleagues [6] performed isolated ligation or wedge excision without pleurodesis for half of their patients, and subsequently added apical pleurectomy to the procedure. The important issues to be compared with open surgery are the incidence of postoperative complications and the quality of long-term results in terms of recurrence.
Complications It is surprising to perceive that complications rates are quite similar to thoracotomy [29]: the magic of surgery without incision does not prevent complications! In the series presented by Mouroux and colleagues [26], the cumulative complication rate was 10%. When considering the cause of pneumothorax, the complication rate was 6.75% for primary pneumothorax versus 27.7% for secondary pneumothorax; these figures again equal those achieved with thoracotomy [26]. The most frequent complication is prolonged air leak (.5 days), which is observed in approximately 8% of patients [6, 27, 30]. Failing pleurodesis and hemothorax require reoperation; the incidence of reoperation has been close to 5% [25].
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Table 3. Recurrence Rates After Video-Assisted Thoracic Operations for Spontaneous Pneumothorax Authors Naunheim et al [27] Yim and Ho [30] Inderbitzi et al [6] Bertrand et al [25] Mouroux et al [26]
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Patients Follow-up 113 100 79 163 100
13.1 17 19.6 24.5 30
Recurrence Lost to (%) Follow-up 4.1 4 8.3 3.6a 3
10 NS 6.3 8.5 NS
a
The long-term recurrence rate was 3.6%, but four early failures requiring reoperation by thoracotomy occurred, which equals a total of 6% of failures. NS 5 not stated.
Recurrence After Operation Most series suggest that the medium-term (less than 3 years of follow-up) rate of recurrence after VATS procedures is between 5% and 10% (Table 3) [25–30]. To be perfectly honest, “failure during hospitalisation treated by thoracotomy” [29] should be considered an early recurrence. Recurrences are certainly increased when compared with thoracotomy: in a historical comparison by Dumont and colleagues [29], the recurrence rate was 0.4% after thoracotomy and 6% after VATS (x2 5 10.635; p , 0.01) [29]. A multicenter study by Naunheim and colleagues [27] reports a somewhat heterogeneous series of 113 patients, because the method of pleurodesis differed: abrasion, 45%; sclerotic agents, 24%; laser, 13%; pleurectomy, 10%; none, 10%. The overall recurrence rate was 4.1%, and actuarial freedom of recurrence was estimated 95% at 6 months. Similarly, Bertrand and colleagues [25] reported a freedom of recurrence of 95% at 42 months in a review of 163 patients. In the latter series, 3 patients had a complete recurrence requiring a second operation, and 3 had partial recurrence managed conservatively, which accounts for a recurrence rate of 3.6%. However, 4 patients were reoperated on via thoracotomy for immediate failure during the initial postoperative hospital stay; when these patients are included, the total rate of recurrence is 6% [25]. A National Survey in the United States stated a 7% failure rate in 1993 [31]. No definitive conclusion on recurrence rates can be drawn without a controlled trial. Besides, published series probably underestimate recurrence: follow-up is short and 8.5% to 10% of patients are lost to follow-up [25, 27]. This proportion of patients lost to follow-up seems far too high for a benign disease and short-term surveillance; it is likely that patients with postoperative recurrence choose a different surgeon, as they would do for failed hernia repair or recurring varicose veins. Recurrence is modulated by surgical technique; compared with open surgery it is lowest when both apical resection and pleurodesis have been performed. The importance of apical stapling has been particularly stressed by Naunheim and colleagues [27]. In a univariate analysis, two factors predicted recurrence. When no bleb had been identified, the recurrence rate was 27.3%, versus 0% and 2.7% when one or multiple blebs were
seen. Apical stapling reduced the recurrence rate to 1.8%, versus 23% when no excision was made [27]. Mouroux and colleagues [26] confirmed these data in a series comprising 100 consecutive patients. The overall recurrence rate was 3%; 2 of 10 patients without apical stapling had recurrence (20%) versus 1 of 87 in whom an apical lesion had been wedged (1.5%). The importance of pleurodesis is nicely demonstrated by Inderbitzi and colleagues [6], who observed a total of 6 recurrences in 72 patients followed up (8.3%). However, a more precise analysis shows varying results according to technical details: it appears that combined resection of blebs and pleurodesis is the safest treatment [6] (Table 4). Inderbitzi and colleagues themselves consider that isolated ligation has a failure rate of 19.2%, when including prolonged air leaks; therefore, the results do not differ from those of simple chest tube drainage! Chemical pleurodesis instead of abrasion or pleurectomy is also less successful; the combination of thoracoscopic bullectomy and tetracycline pleurodesis resulted in an early failure rate of 9% [32].
Causes of Recurrence The universal argument forwarded to explain an increased failure rate is the learning curve of a new technology. Bertrand and colleagues [25] have demonstrated a nonsignificant difference between two subsequent time periods in their experience: there were five recurrences in the first 97 patients, and only one in the following 66. However, most of these operations were performed by surgical residents, both the open and closed operations. Because the individual learning curve of surgical residents starts at each rotation, this argument is not reliable. Why should there be less success when the technique allows for improved vision in comparison with a minithoracotomy? A first reason might be that fewer blebs are recognized and treated during VATS [25]. Open operation was usually performed with single-lumen intubation, whereas VATS requires double-lumen intubation and one-lung ventilation. It is probable that during VATS operations some blebs are deflated together with the lung and therefore missed. This hypothesis is confirmed by the observation that in patients who undergo reoperation, the causes of failure are most often unrecognized blebs or bullae. A second reason might be a certain degree of fear to abrade! With the magnification, the perception of hem-
Table 4. Recurrence With Respect to Operative Technique, According to Inderbitzi and Associates [6] Recurrence Technique
No.
Percent
Isolated ligation of bulla Isolated wedge resection Isolated pleurectomy Pleurectomy 1 wedge
3/26 1/14 1/16 1/18
11.5% 7.1% 6.3% 5.6%
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orrhage is exaggerated, and a less than optimal abrasion may be performed. Finally, the area between the trocars remains out of view and may not be abraded adequately. The lower degree of tissue trauma and the less intense biologic reaction observed with VATS might be a determinant factor of less efficient pleurodesis: release of inflammatory and vasoactive mediators (C reactive protein, prostacyclin and thromboxane A2) was significantly lower in VATS patients as compared with a similar sample of thoracotomy patients [33].
Table 6. Comparative Duration of Postoperative Chest Tube Drainage
Potential Advantages of Video-Assisted Thoracic Surgery
VATS 5 video-assisted thoracic surgery.
Duration of Postoperative Hospital Stay and Professional Disability
teams than to the surgical method itself. Video-assisted thoracic surgery has certainly caused several teams to shorten their routines of drainage (Table 6).
Comparisons between recent VATS series and former thoracotomies demonstrate an apparent gain of approximately 4 days on postoperative hospital stay (Table 5). However, this reduction of hospital stay is not solely explained by the new technology. Without any doubt, economic considerations have had a major impact on discharge policy in European centers as well as during the most recent years. Economic pressure on patients and physicians encourages earlier return to work. Because VATS is considered “less than surgery,” patients are discharged earlier than the 6th postoperative day. In former series, even axillary thoracotomy was often regarded as a reason for routine hospitalization for at least 10 days, although patients may have been fit for an earlier discharge. Owing to a policy of health insurance, hospital stay remains prolonged in France when compared with other European countries or North America (see Table 5). However, hospital stay could be further reduced by 1.3 days owing to operation under local anesthesia and sedation [28].
Duration of Drainage Duration of drainage is obviously one of the main determinants of hospital stay after any kind of thoracic operation. We agree with Mouroux and colleagues [26] that variations in duration of drainage appear attributable more to the number of drains and to the habits of surgical Table 5. Comparative Duration of Postoperative Hospital Stay
Authors Bertrand et al [25] Dumont et al [29] Mouroux et al [26] Bernard et al [34] Inderbitzi et al [6] Naunheim et al [27] Yim and Ho [30]
Country France France France France Switzerland United States Hong Kong
VATS 5 video-assisted thoracic surgery.
Hospital Hospital Stay/ Stay/VATS Thoracotomy (days) (days) 6.9 9.5 8 7 4.2 4.3 4
10.3 14 ... 11.5 ... ... ...
Authors Dumont et al [29] Mouroux et al [26] Bernard et al [34] Bertrand et al [25] Inderbitzi et al [6] Yim and Ho [30]
Country
Drainage/ VATS
Drainage/ Thoracotomy
France France France France Switzerland Hong Kong
6.5 days 5 days 5 days 4.4 days 46 h 2 days
8 days ... ... 5.6 days ... ...
Postoperative Pain Of course, a considerable reduction in postoperative pain is expected when operative trauma to the chest wall is reduced, and more particularly if an operation is performed without spreading the ribs. Nevertheless, assessment of postoperative pain remains a challenging issue. Evaluation may rely either on subjective analogue scales or on morphine consumption. Besides, the personal experience in postoperative pain management varies from one surgical team to another, which may be the determinant of any difference. The latter is illustrated at a generalized level beyond the single problem of pneumothorax by a most provocative study published by Furrer and colleagues [35]. Furrer and colleagues compared two modes of analgesia together with two types of operations. A first group of patients underwent lobectomy through a posterolateral thoracotomy and were managed with epidural analgesia; the second group included wedge excisions by VATS, and patient-controlled analgesia. It appears that pain was very similar in the two groups: the pain intensity score ranged from 0.4 to 1.6 in the first group and from 0.3 to 1.2 in the second group. Postoperative forced expiratory volume in 1 second and vital capacity (compared with the predicted postoperative function in lobectomy patients, and with preoperatively measured values in VATS patients) were similar on postoperative day 1 and on discharge as well. One third of each group complained of chronic chest pain postoperatively. Furrer and associates [35] conclude that the drawbacks of a classic thoracotomy may be compensated with accurate pain management. Back in the domain of pneumothorax, we lack prospective comparative trials. Subjectively, referring to patients operated on bilaterally with thoracotomy and subsequent VATS, the latter procedure appears as less painful. Dumont and colleagues [29] demonstrated a significantly lower level of pain after VATS when compared with a historical control group operated on through a lateral thoracotomy: 42% of VATS patients required level 3 analgesics versus 95% in patients who had formal thoracotomy. With a similar methodology, Hazelrigg and colleagues [36] compared 20 and 26 patients gathered in a
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multicenter trial; 7.7% of VATS patients and 70% of thoracotomy patients required parenteral narcotics after 48 hours. Long-term pain is a distressing problem after thoracotomy. However, its evaluation is subjected to a variable rating. Bertrand and colleagues [25] estimated that 63% of patients experienced residual chest pain after VATS for pneumothorax, which was considered minimal in 58% of them, moderate in 38%, and severe in 4%. Comparatively, 61% had persistent pain after a lateral thoracotomy for pneumothorax, and the pain was considered minimal in 65%, moderate in 33%, and severe in 2%. Mouroux and colleagues [26] reported a similar incidence of 3% of severe chest pain. Surprisingly, chronic pain has not been reduced by VATS; one should not neglect crushing injury to the intercostal nerves when relatively large instruments are used in narrow intercostal spaces. Motility of the shoulder recovered completely within 1 month after VATS and in only 62% of patients at 3 months after posterolateral thoracotomy (p , 0.0001) [34]; the latter should be tempered by the fact that many surgeons have preferred muscle-sparing incisions for benign disorders.
Return to Activity Return to occupational activity has been evaluated in two series with reference to historical control groups. A first series demonstrated a return to activity within a mean of 42 days after VATS and 74 days after thoracotomy [25]. In this second series comparing two groups of 16 patients, return to work was possible 1 month after VATS and 2.6 months after thoracotomy (p , 0.002); leisure activities were resumed at 2 months after VATS and 4 months after thoracotomy (p , 0.0005) [34]. However, a controlled, prospective study is lacking; one should not neglect a changing philosophy toward postoperative recovery between these two historical comparisons.
Cost Unfortunately, pneumothorax is a common problem and as such accounts for a considerable expenditure of money and resources. Quite naturally, most authors interested in cost analysis conclude that VATS is less expensive owing to a shorter hospital stay [37]. Dumont and colleagues [29] demonstrated a difference of 4.5 days between a cohort of VATS patients and a historical control group. The estimated reduction in cost was $2,300, whereas the increase in cost due to stapling material was estimated at $245. The shorter hospital stay should counterbalance the enhanced cost of disposable material used intraoperatively. These conclusions are biased by the consideration that the reduced hospital stay is not solely due to a changing operative approach. Accurate cost analysis should not only focus on hospital stay, which might be the same for VATS as for an open operation with a limited thoracotomy such as the transaxillary variant [4, 23], owing to an improved discharge policy. It is therefore surprising that none of these studies made any attempt to consider the cost of video equipment, which has simply been considered to be in
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place to be used. Therefore, we have to refer to a recent evaluation of patients undergoing lung biopsy, which is a very similar operation. This study has demonstrated that VATS increases the cost over minithoracotomy by $1,000 when the cost of video equipment is taken into account [38]. Similarly, Allen and colleagues [39] estimated the median operating room charge at $1,970 for VATS versus $778 for thoracotomy. Miller [40] estimated that the total cost was $10,400 for VATS procedures versus $6,150 to $6,750 for thoracotomy; he concluded that at the present time, there is no procedure that can be done more cheaply by video-assisted thoracoscopy than by conventional open technique. Hidden costs include prolonged operating room time, VATS equipment, and disposable material, but also the increased cost of double-lumen catheter intubation, which is mandatory for VATS. The disposables are more expensive; most anesthesiologists perform bronchoscopy to check adequate position of the tube, and induction of anesthesia takes more time. Fear of missing blebs during thoracoscopy leads to a “high-tech” management including routine computed tomographic scan to obviate blebs [41]. To control the total cost, it seems reasonable to withhold computed tomographic scan in patients with primary spontaneous pneumothorax because it should not affect patients’ treatment [42]. The cost of expanded indications has never been alluded to [43]: some authors now advocate definite treatment at the first episode [5]. Cost of recurrence should also be considered; in addition, the psychologic impact of recurrence in patients who have undergone operation is inevaluable [44].
Randomized Trials Despite the relative frequency of spontaneous pneumothorax, there are only two controlled studies available to date. Both conclude there is relatively poor performance of VATS in comparison with open operation with limited incisions. Waller and colleagues [45] compared VATS and thoracotomy in a consecutive series of 60 patients, who were followed up for a median period of 15 to 16 months. All patients were treated by bleb resection and apical pleurectomy; thoracotomy was a limited posterolateral incision carried through the auscultatory triangle. Operative time was longer by 8 minutes in the VATS group (p , 0.01). There was no difference in morphine consumption, in duration of drainage, or in hospital stay. However, postoperative forced expiratory volume in 1 second was lower in the thoracotomy group. Kim and colleagues [46] have compared VATS and transaxillary minithoracotomy. Operative time, amount of analgesics, and chest tube drainage time were very similar. However, 4 of 30 patients managed with VATS did have recurrence. Kim and colleagues concluded that transaxillary minithoracotomy is the preferred approach owing to the lower cost and improved cosmetic result.
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Conclusions and Perspectives for Video-Assisted Thoracic Surgery The two final questions are the following: Should minimally invasive surgery allow for expanded indications? Considering its debatable reliability, is there any future for VATS in recurrent pneumothorax? When going through recent publications, there is an obvious shift of indications, because most teams perform an operation at the second episode. This seems reasonable, because the spontaneous recurrence rate is certainly in excess of 50%. Recent work also demonstrated that an air leak is unlikely to seal beyond 48 hours; operative management of persisting pneumothorax therefore may reasonably be performed at an earlier stage. In contrast, we consider excessive the suggestion that “VATS should be considered in patients with a first episode of idiopathic spontaneous pneumothorax, because these predominantly young patients may profit most from definitive therapy” [6]. Although thoracoscopy might immediately identify patients at risk for recurrence by disclosing blebs, there is no argument in favor of a correlation between thoracoscopic findings and patterns of recurrence [17]. Outside of large teaching hospitals, emergency thoracoscopy under local anesthesia is further limited by the availability of experienced and skilled physicians [19]. Schramel and colleagues [5] concluded that VATS should be performed for first episodes, by comparing total cost of conservative management and thoracoscopic management over two time periods. However, this study is biased because surgical patients of the historical control group underwent formal thoracotomy; when total hospitalization is taken into account, including “waiting time before VATS,” cost efficiency does not appear. We note that in a country like France, daily hospital charges double when comparing a medical ward with a surgical unit; even with similar duration of hospital stay, chest tube drainage in a medical ward reduces the cost by 50%. Besides, the 80% of patients who will not have recurrence are subjected to an unnecessary surgical procedure. Cole and colleagues [47] concluded that VATS should not be considered as the standard treatment of spontaneous pneumothorax: postoperative complications are similar to open procedures, but long-term results are less valuable. This conclusion is perhaps unfair when assigned to a definitive statement. Video-assisted thoracic surgery is an interesting tool for teaching hospitals, because the teacher can adequately follow the trainee. Video-assisted thoracic surgery is obviously less painful than a posterolateral or lateral thoracotomy. Videoassisted thoracic surgery has indirectly contributed to promote a cost-effective discharge policy. Increased experience should lead to improved results. In fine, surgical judgement, not a drive for novelty, must be used to compare thoracoscopic surgery with an open operation through a short axillary incision [48]. When cost is a problem, the transaxillary technique appears as a valuable alternative with anticipated equal immediate re-
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sults, and probably improved long-term results. Therefore, a large, controlled study comparing VATS and transaxillary approach is more than desirable.
References 1. Dumarest F. La pratique du pneumothorax the´rapeutique. Paris: Masson, 1945. 2. Wied U, Halkier E, Hoeier-Madsen K, Plucnar B, Rasmussen E, Sparup J. Tetracycline versus silver nitrate pleurodesis in spontaneous pneumothorax. J Thorac Cardiovasc Surg 1983; 86:591–3. 3. Gue´rin JC, Champel F, Biron E, Kalb JC. Talcage pleural par thoracoscopie dans le traitement du pneumothorax. Rev Mal Respir 1985;2:25–9. 4. Becker RM, Munro DD. Transaxillary minithoracotomy: the optimal approach for certain pulmonary and mediastinal lesions. Ann Thorac Surg 1976;22:254–9. 5. Schramel FM, Sutedja TG, Braber JC, van Mourik JC, Postmus PE. Cost-effectiveness of video-assisted thoracoscopic surgery versus conservative treatment for first time or recurrent spontaneous pneumothorax. Eur Respir J 1996;9:1821–5. 6. Inderbitzi RGC, Leiser A, Furrer M, Althaus U. Three years experience in video-assisted thoracic surgery (VATS) for spontaneous pneumothorax. J Thorac Cardiovasc Surg 1994; 107:1410–5. 7. Cran IR, Rumball CA. Survey of spontaneous pneumothorax in the Royal Air Force. Thorax 1967;22:462–5. 8. Gaensler EA. Parietal pleurectomy for recurrent spontaneous pneumothorax. Surg Gynecol Obstet 1956;102:293–308. 9. Clagett OT. The management of spontaneous pneumothorax. J Thorac Cardiovasc Surg 1968;55:761–2. 10. Dumont P, Nebia A, Roeslin N, Massard G, Wihlm JM, Morand G. Traitement chirurgical du pneumothorax. Etude d’une se´rie de 400 cas. Ann Chir 1995;49:235– 40. 11. Thomas P, Le Mee F, Le Hors H, et al. Re´sultats du traitement chirurgical des pneumothorax persistants ou re´cidivants. Ann Chir 1993;47:136– 40. 12. The´venet F, Gamonde`s JP, Bodzongo D, Balawi A. Pneumothorax spontane´ et re´cidivant. Traitement chirurgical. A propos de 278 observations. Ann Chir 1992;46:165–9. 13. Weeden D, Smith GH. Surgical experience in the management of spontaneous pneumothorax, 1972– 82. Thorax 1983; 38:737– 43. 14. Ko¨rner H, Andersen KS, Stangeland L, Ellingsen I, Engedal H. Surgical treatment of spontaneous pneumothorax by wedge resection without pleurodesis or pleurectomy. Eur J Cardiothorac Surg 1996;10:656–9. 15. Olsen PS, Andersen HO. Long-term results after tetracycline pleurodesis in spontaneous pneumothorax. Ann Thorac Surg 1992;53:1015–7. 16. Walker-Renard PB, Vaughan ML, Sahn SA. Chemical pleurodesis for malignant pleural effusion. Ann Intern Med 1994; 120:56– 64. 17. Almind M, Lange P, Viskum K. Spontaneous pneumothorax: comparison of simple drainage, talc pleurodesis, and tetracycline pleurodesis. Thorax 1989;44:627–30. 18. El Khawand C, Marchandise FX, Mayne A, et al. Pneumothorax spontane´. Re´sultats du talcage sous thoracoscopie. Rev Mal Respir 1995;12:275– 81. 19. Van de Brekel JA, Duurkens VA, Vanderschueren RG. Pneumothorax. Results of thoracoscopy and pleurodesis with talc poudrage and thoracotomy. Chest 1993;103:345–7. 20. Chappel AG, Johnson A, Charles J, et al. A survey of the long term effects of talc and kaolin pleurodesis. Br J Dis Chest 1979;73:285– 8. 21. Lange P, Mortensen J, Groth S. Lung function 22–35 years after treatment of idiopathic spontaneous pneumothorax with talc poudrage or simple drainage. Thorax 1988;43: 559– 61. 22. Gue´rin JC, Van Der Schueren RG. Traitement des pneumo-
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thorax re´cidivants par application de colle de fibrine sous endoscopie. Rev Mal Respir 1989;6:443–5. Deslauriers J, Beaulieu M, Despre´s JP, et al. Transaxillary pleurectomy for treatment of spontaneous pneumothorax. Ann Thorac Surg 1980;30:569–74. Simansky DA, Yellin A. Pleural abrasion via axillary thoracotomy in the era of video assisted thoracic surgery. Thorax 1994;49:922–3. Bertrand PC, Regnard JF, Spaggiari L, et al. Immediate and long-term results after surgical treatment of primary spontaneous pneumothorax by VATS. Ann Thorac Surg 1996;61: 1641–5. Mouroux J, Elkaı¨m D, Padovani B, et al. Video-assisted thoracoscopic treatment of spontaneous pneumothorax: technique and results of one hundred cases. J Thorac Cardiovasc Surg 1996;112:385–91. Naunheim KS, Mack MJ, Hazelrigg SR, et al. Safety and efficacy of video-assisted thoracic surgical techniques for the treatment of spontaneous pneumothorax. J Thorac Cardiovasc Surg 1995;109:1198 –204. Nezu K, Kushibe K, Tojo T, Takahama M, Kitamura S. Thoracoscopic wedge resection of blebs under local anesthesia with a sedation for treatment of a spontaneous pneumothorax. Chest 1997;111:230–5. Dumont P, Diemont F, Massard G, Toumieux B, Wihlm JM, Morand G. Does a thoracoscopic approach for surgical treatment of spontaneous pneumothorax represent progress? Eur J Cardiothorac Surg 1997;11:27–31. Yim AP, Ho JK. One hundred consecutive cases of videoassisted thoracoscopic surgery for primary spontaneous pneumothorax. Surg Endosc 1995;9:322– 6. Miller JI. Discussion of Cole FH Jr, Cole FH, Khandekar A, Maxwell JM, Pate JW, Walker WA. Video-assisted thoracic surgery: primary treatment for spontaneous pneumothorax? Ann Thorac Surg 1995;60:931–5. Waterworth PD, Kallis P, Townsend ER, Fountain SW. Thoracoscopic bullectomy and tetracycline pleurodesis for the treatment of spontaneous pneumothorax. Respir Med 1995;89:563– 6. Gebhard FT, Becher HP, Gerngross H, Bruckner UB. Reduced inflammatory response in minimal invasive surgery of pneumothorax. Arch Surg 1996;131:1079– 82. Bernard A, Be´lichard C, Goudet P, Lombard JN, Viard H. Pneumothorax spontane´. Comparaison de la thoracoscopie et de la thoracotomie. Rev Mal Respir 1993;10:433– 6.
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35. Furrer M, Rechsteiner R, Eigenmann V, Signer C, Althaus U, Ris HB. Thoracotomy and thoracoscopy: post-operative pulmonary function, pain and chest wall complaints. Eur J Cardiothoracic Surg 1997;12:82–7. 36. Hazelrigg SR, Landreneau RJ, Mack M, et al. Thoracoscopic stapled resection for spontaneous pneumothorax. J Thorac Cardiovasc Surg 1993;105:389–93. 37. Crisci R, Coloni GF. Video-assisted thoracoscopic surgery versus thoracotomy for recurrent spontaneous pneumothorax. A comparison of results and costs. Eur J Cardiothorac Surg 1996;10:556– 60. 38. Molin LJ, Steinberg JB, Lanza LA. VATS increases costs in patients undergoing lung biopsy for interstitial lung disease. Ann Thorac Surg 1994;58:1595– 8. 39. Allen MS, Deschamps C, Lee RE, Trastek VF, Daly RC, Pairolero PC. Video-assisted thoracoscopic stapled wedge excision for indeterminate pulmonary nodules. J Thorac Cardiovasc Surg 1993;106:1048–52. 40. Miller JI Jr. The present role and future considerations of video-assisted thoracoscopy in general thoracic surgery. Ann Thorac Surg 1993;56:804– 6. 41. Warner BW, Bailey WW, Shipley RT. Value of computed tomography of the lung in the management of primary spontaneous pneumothorax. Am J Surg 1991;162:39– 42. 42. Jordan KG, Kwong JS, Flint J, Muller NL. Surgically treated pneumothorax: radiologic and pathologic findings. Chest 1997;111:280–5. 43. Van Schil P. Comparison of costs between video-assisted thoracic surgery (VATS) and thoracotomy. Eur J Cardiothorac Surg 1997;12:166–7. 44. Nazari S. Psychological implications in the surgical treatment of pneumothorax. Ann Thorac Surg 1997;63:1830–1. 45. Waller DA, Forty J, Morritt GN. Video-assisted thoracoscopic surgery versus thoracotomy for spontaneous pneumothorax. Ann Thorac Surg 1994;58:372–7. 46. Kim KH, Kim HK, Han JY, Kim JT, Won YS, Choi SS. Transaxillary minithoracotomy versus video-assisted thoracic surgery for spontaneous pneumothorax. Ann Thorac Surg 1996;61:1510–2. 47. Cole FH Jr, Cole FH, Khandekar A, Maxwell JM, Pate JW, Walker WA. Video-assisted thoracic surgery: primary treatment for spontaneous pneumothorax? Ann Thorac Surg 1995;60:931–5. 48. Ribet ME. Thoracoscopic surgery for pneumothorax. J Thorac Cardiovasc Surg 1964;107:312–3.
Minimally Invasive Management for First and Recurrent Pneumothorax Gilbert Massard, MD, Pascal Thomas, MD, and Jean-Marie Wihlm, MD Departments of Thoracic Surgery, Hoˆpitaux Universitaires de Strasbourg and Hoˆpital Sainte Marguerite, Marseille, France
Minimally invasive techniques for treatment of pneumothorax should yield the standard of results set with open procedures: the operative morbidity should remain less than 15%, and the recurrence rate less than 1%. In the era before video-assisted thoracic surgery, two minimally invasive variants were used. Chemical pleurodesis resulted in an unsatisfactory recurrence rate of at least 15%. In contrast, pleurectomy and apical stapling performed through a transaxillary minithoracotomy compared favorably with larger thoracotomy approaches, and allowed a reduced hospital stay. Evaluation of videoassisted thoracic surgical operations for spontaneous pneumothorax is hampered by a lack of controlled studies. The general impression is that morbidity did not decline significantly; the main determinant of complications is the patient’s underlying health status. However, published recurrence rates range from 5% to 10%, in spite
of a shorter follow-up time span. Optimized results are achieved when classic principles combining apical wedge resection and pleurodesis are applied. Reduction of hospital stay is not only a result of the new technology, but also changing drainage and discharge policies. Reduction of cost is debatable, because many studies do not consider the cost of video equipment. The main advantage when compared with open thoracotomy is reduction of postoperative pain. The only two available controlled studies conclude that there is no obvious advantage of video-assisted thoracic surgery when compared with conventional limited-access surgery. The future role of video-assisted thoracic surgery in this disease remains to be determined by a large-scale prospective evaluation.
R
of spontaneous pneumothorax, the reader may be misled. Most articles review a patient population including both primary and secondary spontaneous pneumothorax. There is also a varying algorithm of indications for surgical management: the “newborn tool” stimulates surgical activism, and some over-enthusiastic authors advocate aggressive management as soon as the first episode [5]. Over the past 4 years, many articles have been published with the conclusion that VATS has definitely proved itself as the gold standard of treatment for spontaneous pneumothorax. Surprisingly, in the era of evaluation and accreditation, this statement has not been founded on large-scale controlled studies. The present review has been made of the most relevant articles selected by a screening of the Medline database; some historical references have been chosen according to the frequency of citation. Results achieved with open operation have been considered as the standard that should be equalled by less invasive techniques. Early and long-term results of minimally invasive techniques such as chemical pleurodesis, minithoracotomy, and video-assisted surgery are discussed. The potential advantages of video-assisted surgery, in terms of postoperative hospital stay, pain, and eventually cost of treatment, have been critically reviewed.
ecurrent spontaneous pneumothorax is a disabling disorder, which may present either in young and otherwise healthy patients (primary pneumothorax) or as a complication of an underlying lung disease (secondary pneumothorax). Both patient populations should take advantage of the least invasive management preventing further recurrence. Minimally invasive techniques should shorten hospital stay and physical disability, and should lower the cost of treatment, while yielding at least comparable long-term results in comparison with standard open procedures. The recent advent of video-assisted thoracic surgery (VATS) for treatment of spontaneous pneumothorax evolves together with a double paradox. The first paradox is that thoracoscopy has been used during nearly half a century to create artificial pneumothorax as a treatment for tuberculosis [1]! The second paradox is that the concept of minimally invasive surgery, usually presented as a recent innovation, has had its partisans for more than 40 years. Many chest physicians used to perform chemical pleurodesis, either blind or with thoracoscopy, with varying success rates [2, 3]. Pleurectomy via an axillary minithoracotomy, as described in 1976, should be considered a minimally invasive operation, with respect to reduced pain, early discharge, and excellence of the cosmetic result [4]. When going through publications dealing with treatment Address reprint requests to Dr Massard, Department of Thoracic Surgery, Hoˆpitaux Universitaires de Strasbourg, F-67091 Strasbourg, France (email: [email protected]).
© 1998 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
(Ann Thorac Surg 1998;66:592–9) © 1998 by The Society of Thoracic Surgeons
Historical Reference: Surgical Treatment With Thoracotomy Any new treatment modality should compare at least equally well in terms of operative risk and long-term 0003-4975/98/$19.00 PII S0003-4975(98)00621-3
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Table 1. Outcome After Open Operation for Spontaneous Pneumothorax Authors Thomas et al [11] Dumont et al [10] The´venet et al [12] Weeden and Smith [13] Ko¨rner et al [14]
Number
Pleurodesis
107 400 278 233 120
Abrasion Abrasion Pleurectomy Pleurectomy None
Complications (%)
Recurrence (%)
Follow-up (mo)
14 15 6.5 17
0 0.25 1 0.4 5
27 NS 84 56
NS 5 not stated.
results to open thoracotomy, which has set the standard of excellence to be challenged. Classically, the timing of operative intervention should refer to the spontaneous potential of recurrence. Lowest estimates of recurrence after simple chest tube drainage of a first episode range from 10% to 21%; recurrence after a second episode is estimated close to 50%, and close to 80% after a third episode [6, 7]. According to the statistical risk of recurrence, indications for operative intervention have been universally recognized for many years as follows: Second ipsilateral recurrence First contralateral recurrence Bilateral simultaneous pneumothorax Persisting pneumothorax (air leaks beyond day 7 of tube drainage) Spontaneous hemopneumothorax Professions at risk (eg, pilots, scuba divers) Surgical management of pneumothorax has a double objective. Virtually all authors agree that the cause should be treated by resection of blebs, suture of apical perforations, and even blind apical stapling when no obvious lesion has been identified. The second aim of treatment is to create diffuse adhesions to prevent any further recurrence. Long-standing and still unresolved discussion has opposed the proponents of partial or total pleurectomy to the partisans of pleural abrasion [8, 9]. The former believe that pleurectomy is the more efficient treatment, whereas the latter speculate that abrasion preserves the extrapleural plane for a hypothetic and future thoracotomy. Several authors added treatment of the visceral pleura by iodine or silver nitrate [10, 11]. In fine, most published large-scale series show outstanding long-term results with a recurrence rate of less than 1%, regardless of whether the pneumothorax is primary or secondary and whether an abrasion or a pleurectomy has been performed (Table 1) [11–13]. A previous review of the literature, however, demonstrated a slight advantage of pleurectomy over abrasion: the recurrence rate was 0.4% after pleurectomy (n 5 752) and 2.3% after abrasion (n 5 301) [13]. Although the primum movens of spontaneous pneumothorax is a lung disorder, pleurodesis appears to be mandatory: Ko¨rner and colleagues [14] have performed apical wedge resections without pleurodesis through thoracotomy, resulting in a recurrence rate of 5%. The incidence of postoperative complications has been
close to 15% (see Table 1). However, most complications are related to the patient’s status (chronic obstructive pulmonary disease) rather than to the thoracotomy itself. When separating primary and secondary pneumothorax, it appeared that significantly more complications occurred in patients with underlying lung disease: the respective rates were 26.3% for secondary pneumothorax and 7.2% for primary pneumothorax (p , 0.01) [11]. The main complications were hemothorax and prolonged air leaks. Postoperative hemothorax is seen more particularly after pleurectomy, and occurred in 0% to 4% of cases. Total pleurectomy led to an increased complication rate when compared with apical pleurectomy [13]. Prolonged air leaks have been observed in 5% to 10% of patients, and were more frequent in patients with chronic obstructive pulmonary disease [10]. Despite the relatively recent time period reviewed in the work referenced in Table 1, hospital stay was prolonged to a mean of 14 days. This prolonged stay was partially explained by cultural reasons: chest tubes were left in place for 4 to 6 days as a rule, and thoracotomy was thought to require a hospitalization of at least 12 days. Nonetheless, hospital stay was prolonged by 4 days in patients with secondary pneumothorax [11].
“Historic” Alternatives to Thoracotomy In past years, two alternatives to a formal thoracotomy were used: chemical pleurodesis with thoracoscopy under local anesthesia, and apical pleurectomy combined with resection of blebs via a transaxillary minithoracotomy. Both methods may be considered minimally invasive in terms of postoperative pain, shortened hospital stay, and cosmetic result when compared with conventional operations with standard thoracotomy.
Chemical Pleurodesis Chemical pleurodesis has been promoted by chest physicians comfortable with thoracoscopy, thus prolonging the traditions of phtysiology. Instillation of irritating substances into the pleural space should cause local aseptic inflammation leading to dense adhesions. The most popular agents have been talc, tetracycline, and silver nitrate, which share the substantial advantage of a low cost. However, silver nitrate application is particularly painful, and induces a major exudative reaction; therefore, its use has not been reported in recent publications [2]. Injectable tetracycline is no longer commer-
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Table 2. Success Rates With Talc Poudrage for Spontaneous Pneumothorax Authors Gue´rin et al [3] El Khawand et al [18] Van de Brekel et al [19]
Patients
Success Rate
109 200 356
87% 92.7% 88%
cially available; besides, results were not really satisfactory, because the recurrence rate was estimated at 16% in a series of 390 consecutive patients [15]. Talc poudrage has the lowest recurrence rate of all chemical agents [16]. In a comparative trial including 96 patients, the recurrence rate was 36% after simple drainage, 13% after tetracycline pleurodesis, and 8% after talc poudrage [17]. The overall failure rate of talc poudrage is probably higher and may be estimated at 10% to 15% [3, 18, 19] (Table 2). According to Gue´rin and colleagues [3], half of the failures were immediate failures, prompting subsequent thoracotomy. In addition to a relatively high rate of failures, there are several other potential drawbacks of talc poudrage. Fear for asbestos contamination can be excluded reasonably; no single case of mesothelioma has been reported in a survey of 210 patients followed up 14 to 40 years [20]. Further, the threat of restrictive respiratory impairment is apparently unfounded. In a series of 75 patients followed up for 22 to 35 years after talc poudrage, a mild restrictive impairment of lung function (mean total lung capacity, 89% of predicted) was shown [21]. Spirometry showed normal values in 42 patients reviewed by Gue´rin and associates [3]. However, most surgeons favor pleural abrasion or pleurectomy because granuloma formation is considered excessive, and might offer a challenging barrier to any subsequent thoracotomy. In contrast, patchy distribution of talc may fail to prevent recurrences, and may require a subsequent thoracotomy in technically critical conditions. With modern technology, fibrin glue has been tested as a primary treatment for pneumothorax but has shown an unacceptably high recurrence rate of 25% [22]. Therefore, and because of the cost and biologic risks of this material, we do not agree with the statement that fibrin glue might be a valuable alternative to the classic algorithm. The high failure rate of any kind of chemical pleurodesis makes this type of treatment unsuitable for primary spontaneous pneumothorax. Exceptional use of talc poudrage should be restricted to otherwise inoperable patients with secondary pneumothorax.
Transaxillary Minithoracotomy This approach, popularized by Becker and Munro [4] as early as 1976, should by all means be considered a minimally invasive operation in terms of shortness of both incision and hospital stay. The incision is carried at the hairline of the axilla and measures 5 to 6 cm at most; the chest is entered through the third intercostal space. Apical pleurectomy or abrasion is performed, and the apexes of the upper and lower lobe are carefully in-
spected. Blebs or bullae can be drawn to the level of the skin and stapled outside the chest. A single tube is left for 24 hours. A large experience published by Deslauriers and colleagues in 1980 [23] included 362 consecutive patients. Pleurodesis was induced by apical pleurectomy. Four patients required reoperation for bleeding (n 5 3) or air leak (n 5 1), and a further 30 experienced minor complications (9.4%). Mean hospital stay was 6 days. Only 2 patients (0.4%) presented with recurrent pneumothorax. Without any doubt, this straightforward procedure is efficient as far as operating room cost is concerned. Cosmetic results are excellent. Long-term results are optimal. A recent reappraisal by Simansky and Yellin [24] confirmed a reduced hospital stay averaging 4.6 days. However, the recurrence rate among 39 consecutive patients was 4.6% at a mean follow-up of 33 months. The relatively high failure rate could be explained by the fact that bullae were treated with laser coagulation rather than by stapled resection; abrasion was performed instead of pleurectomy to induce pleurodesis.
Overall Results With Video-Assisted Thoracic Surgery To maintain quality at the previously established levels, the fundamental rule of any kind of minimally invasive operation is to perform the same operative procedure as in open surgery, the only difference being the chest wall incision. As expected after the previous debate on pleurodesis, most authors have merely transferred their usual technique to minimally invasive procedure. The largest series published to date favor abrasion [25–27]. Some single series advocate exclusive resection of blebs without pleurodesis [28]. Other authors have changed their technique with growing experience; Inderbitzi and colleagues [6] performed isolated ligation or wedge excision without pleurodesis for half of their patients, and subsequently added apical pleurectomy to the procedure. The important issues to be compared with open surgery are the incidence of postoperative complications and the quality of long-term results in terms of recurrence.
Complications It is surprising to perceive that complications rates are quite similar to thoracotomy [29]: the magic of surgery without incision does not prevent complications! In the series presented by Mouroux and colleagues [26], the cumulative complication rate was 10%. When considering the cause of pneumothorax, the complication rate was 6.75% for primary pneumothorax versus 27.7% for secondary pneumothorax; these figures again equal those achieved with thoracotomy [26]. The most frequent complication is prolonged air leak (.5 days), which is observed in approximately 8% of patients [6, 27, 30]. Failing pleurodesis and hemothorax require reoperation; the incidence of reoperation has been close to 5% [25].
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Table 3. Recurrence Rates After Video-Assisted Thoracic Operations for Spontaneous Pneumothorax Authors Naunheim et al [27] Yim and Ho [30] Inderbitzi et al [6] Bertrand et al [25] Mouroux et al [26]
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Patients Follow-up 113 100 79 163 100
13.1 17 19.6 24.5 30
Recurrence Lost to (%) Follow-up 4.1 4 8.3 3.6a 3
10 NS 6.3 8.5 NS
a
The long-term recurrence rate was 3.6%, but four early failures requiring reoperation by thoracotomy occurred, which equals a total of 6% of failures. NS 5 not stated.
Recurrence After Operation Most series suggest that the medium-term (less than 3 years of follow-up) rate of recurrence after VATS procedures is between 5% and 10% (Table 3) [25–30]. To be perfectly honest, “failure during hospitalisation treated by thoracotomy” [29] should be considered an early recurrence. Recurrences are certainly increased when compared with thoracotomy: in a historical comparison by Dumont and colleagues [29], the recurrence rate was 0.4% after thoracotomy and 6% after VATS (x2 5 10.635; p , 0.01) [29]. A multicenter study by Naunheim and colleagues [27] reports a somewhat heterogeneous series of 113 patients, because the method of pleurodesis differed: abrasion, 45%; sclerotic agents, 24%; laser, 13%; pleurectomy, 10%; none, 10%. The overall recurrence rate was 4.1%, and actuarial freedom of recurrence was estimated 95% at 6 months. Similarly, Bertrand and colleagues [25] reported a freedom of recurrence of 95% at 42 months in a review of 163 patients. In the latter series, 3 patients had a complete recurrence requiring a second operation, and 3 had partial recurrence managed conservatively, which accounts for a recurrence rate of 3.6%. However, 4 patients were reoperated on via thoracotomy for immediate failure during the initial postoperative hospital stay; when these patients are included, the total rate of recurrence is 6% [25]. A National Survey in the United States stated a 7% failure rate in 1993 [31]. No definitive conclusion on recurrence rates can be drawn without a controlled trial. Besides, published series probably underestimate recurrence: follow-up is short and 8.5% to 10% of patients are lost to follow-up [25, 27]. This proportion of patients lost to follow-up seems far too high for a benign disease and short-term surveillance; it is likely that patients with postoperative recurrence choose a different surgeon, as they would do for failed hernia repair or recurring varicose veins. Recurrence is modulated by surgical technique; compared with open surgery it is lowest when both apical resection and pleurodesis have been performed. The importance of apical stapling has been particularly stressed by Naunheim and colleagues [27]. In a univariate analysis, two factors predicted recurrence. When no bleb had been identified, the recurrence rate was 27.3%, versus 0% and 2.7% when one or multiple blebs were
seen. Apical stapling reduced the recurrence rate to 1.8%, versus 23% when no excision was made [27]. Mouroux and colleagues [26] confirmed these data in a series comprising 100 consecutive patients. The overall recurrence rate was 3%; 2 of 10 patients without apical stapling had recurrence (20%) versus 1 of 87 in whom an apical lesion had been wedged (1.5%). The importance of pleurodesis is nicely demonstrated by Inderbitzi and colleagues [6], who observed a total of 6 recurrences in 72 patients followed up (8.3%). However, a more precise analysis shows varying results according to technical details: it appears that combined resection of blebs and pleurodesis is the safest treatment [6] (Table 4). Inderbitzi and colleagues themselves consider that isolated ligation has a failure rate of 19.2%, when including prolonged air leaks; therefore, the results do not differ from those of simple chest tube drainage! Chemical pleurodesis instead of abrasion or pleurectomy is also less successful; the combination of thoracoscopic bullectomy and tetracycline pleurodesis resulted in an early failure rate of 9% [32].
Causes of Recurrence The universal argument forwarded to explain an increased failure rate is the learning curve of a new technology. Bertrand and colleagues [25] have demonstrated a nonsignificant difference between two subsequent time periods in their experience: there were five recurrences in the first 97 patients, and only one in the following 66. However, most of these operations were performed by surgical residents, both the open and closed operations. Because the individual learning curve of surgical residents starts at each rotation, this argument is not reliable. Why should there be less success when the technique allows for improved vision in comparison with a minithoracotomy? A first reason might be that fewer blebs are recognized and treated during VATS [25]. Open operation was usually performed with single-lumen intubation, whereas VATS requires double-lumen intubation and one-lung ventilation. It is probable that during VATS operations some blebs are deflated together with the lung and therefore missed. This hypothesis is confirmed by the observation that in patients who undergo reoperation, the causes of failure are most often unrecognized blebs or bullae. A second reason might be a certain degree of fear to abrade! With the magnification, the perception of hem-
Table 4. Recurrence With Respect to Operative Technique, According to Inderbitzi and Associates [6] Recurrence Technique
No.
Percent
Isolated ligation of bulla Isolated wedge resection Isolated pleurectomy Pleurectomy 1 wedge
3/26 1/14 1/16 1/18
11.5% 7.1% 6.3% 5.6%
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orrhage is exaggerated, and a less than optimal abrasion may be performed. Finally, the area between the trocars remains out of view and may not be abraded adequately. The lower degree of tissue trauma and the less intense biologic reaction observed with VATS might be a determinant factor of less efficient pleurodesis: release of inflammatory and vasoactive mediators (C reactive protein, prostacyclin and thromboxane A2) was significantly lower in VATS patients as compared with a similar sample of thoracotomy patients [33].
Table 6. Comparative Duration of Postoperative Chest Tube Drainage
Potential Advantages of Video-Assisted Thoracic Surgery
VATS 5 video-assisted thoracic surgery.
Duration of Postoperative Hospital Stay and Professional Disability
teams than to the surgical method itself. Video-assisted thoracic surgery has certainly caused several teams to shorten their routines of drainage (Table 6).
Comparisons between recent VATS series and former thoracotomies demonstrate an apparent gain of approximately 4 days on postoperative hospital stay (Table 5). However, this reduction of hospital stay is not solely explained by the new technology. Without any doubt, economic considerations have had a major impact on discharge policy in European centers as well as during the most recent years. Economic pressure on patients and physicians encourages earlier return to work. Because VATS is considered “less than surgery,” patients are discharged earlier than the 6th postoperative day. In former series, even axillary thoracotomy was often regarded as a reason for routine hospitalization for at least 10 days, although patients may have been fit for an earlier discharge. Owing to a policy of health insurance, hospital stay remains prolonged in France when compared with other European countries or North America (see Table 5). However, hospital stay could be further reduced by 1.3 days owing to operation under local anesthesia and sedation [28].
Duration of Drainage Duration of drainage is obviously one of the main determinants of hospital stay after any kind of thoracic operation. We agree with Mouroux and colleagues [26] that variations in duration of drainage appear attributable more to the number of drains and to the habits of surgical Table 5. Comparative Duration of Postoperative Hospital Stay
Authors Bertrand et al [25] Dumont et al [29] Mouroux et al [26] Bernard et al [34] Inderbitzi et al [6] Naunheim et al [27] Yim and Ho [30]
Country France France France France Switzerland United States Hong Kong
VATS 5 video-assisted thoracic surgery.
Hospital Hospital Stay/ Stay/VATS Thoracotomy (days) (days) 6.9 9.5 8 7 4.2 4.3 4
10.3 14 ... 11.5 ... ... ...
Authors Dumont et al [29] Mouroux et al [26] Bernard et al [34] Bertrand et al [25] Inderbitzi et al [6] Yim and Ho [30]
Country
Drainage/ VATS
Drainage/ Thoracotomy
France France France France Switzerland Hong Kong
6.5 days 5 days 5 days 4.4 days 46 h 2 days
8 days ... ... 5.6 days ... ...
Postoperative Pain Of course, a considerable reduction in postoperative pain is expected when operative trauma to the chest wall is reduced, and more particularly if an operation is performed without spreading the ribs. Nevertheless, assessment of postoperative pain remains a challenging issue. Evaluation may rely either on subjective analogue scales or on morphine consumption. Besides, the personal experience in postoperative pain management varies from one surgical team to another, which may be the determinant of any difference. The latter is illustrated at a generalized level beyond the single problem of pneumothorax by a most provocative study published by Furrer and colleagues [35]. Furrer and colleagues compared two modes of analgesia together with two types of operations. A first group of patients underwent lobectomy through a posterolateral thoracotomy and were managed with epidural analgesia; the second group included wedge excisions by VATS, and patient-controlled analgesia. It appears that pain was very similar in the two groups: the pain intensity score ranged from 0.4 to 1.6 in the first group and from 0.3 to 1.2 in the second group. Postoperative forced expiratory volume in 1 second and vital capacity (compared with the predicted postoperative function in lobectomy patients, and with preoperatively measured values in VATS patients) were similar on postoperative day 1 and on discharge as well. One third of each group complained of chronic chest pain postoperatively. Furrer and associates [35] conclude that the drawbacks of a classic thoracotomy may be compensated with accurate pain management. Back in the domain of pneumothorax, we lack prospective comparative trials. Subjectively, referring to patients operated on bilaterally with thoracotomy and subsequent VATS, the latter procedure appears as less painful. Dumont and colleagues [29] demonstrated a significantly lower level of pain after VATS when compared with a historical control group operated on through a lateral thoracotomy: 42% of VATS patients required level 3 analgesics versus 95% in patients who had formal thoracotomy. With a similar methodology, Hazelrigg and colleagues [36] compared 20 and 26 patients gathered in a
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multicenter trial; 7.7% of VATS patients and 70% of thoracotomy patients required parenteral narcotics after 48 hours. Long-term pain is a distressing problem after thoracotomy. However, its evaluation is subjected to a variable rating. Bertrand and colleagues [25] estimated that 63% of patients experienced residual chest pain after VATS for pneumothorax, which was considered minimal in 58% of them, moderate in 38%, and severe in 4%. Comparatively, 61% had persistent pain after a lateral thoracotomy for pneumothorax, and the pain was considered minimal in 65%, moderate in 33%, and severe in 2%. Mouroux and colleagues [26] reported a similar incidence of 3% of severe chest pain. Surprisingly, chronic pain has not been reduced by VATS; one should not neglect crushing injury to the intercostal nerves when relatively large instruments are used in narrow intercostal spaces. Motility of the shoulder recovered completely within 1 month after VATS and in only 62% of patients at 3 months after posterolateral thoracotomy (p , 0.0001) [34]; the latter should be tempered by the fact that many surgeons have preferred muscle-sparing incisions for benign disorders.
Return to Activity Return to occupational activity has been evaluated in two series with reference to historical control groups. A first series demonstrated a return to activity within a mean of 42 days after VATS and 74 days after thoracotomy [25]. In this second series comparing two groups of 16 patients, return to work was possible 1 month after VATS and 2.6 months after thoracotomy (p , 0.002); leisure activities were resumed at 2 months after VATS and 4 months after thoracotomy (p , 0.0005) [34]. However, a controlled, prospective study is lacking; one should not neglect a changing philosophy toward postoperative recovery between these two historical comparisons.
Cost Unfortunately, pneumothorax is a common problem and as such accounts for a considerable expenditure of money and resources. Quite naturally, most authors interested in cost analysis conclude that VATS is less expensive owing to a shorter hospital stay [37]. Dumont and colleagues [29] demonstrated a difference of 4.5 days between a cohort of VATS patients and a historical control group. The estimated reduction in cost was $2,300, whereas the increase in cost due to stapling material was estimated at $245. The shorter hospital stay should counterbalance the enhanced cost of disposable material used intraoperatively. These conclusions are biased by the consideration that the reduced hospital stay is not solely due to a changing operative approach. Accurate cost analysis should not only focus on hospital stay, which might be the same for VATS as for an open operation with a limited thoracotomy such as the transaxillary variant [4, 23], owing to an improved discharge policy. It is therefore surprising that none of these studies made any attempt to consider the cost of video equipment, which has simply been considered to be in
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place to be used. Therefore, we have to refer to a recent evaluation of patients undergoing lung biopsy, which is a very similar operation. This study has demonstrated that VATS increases the cost over minithoracotomy by $1,000 when the cost of video equipment is taken into account [38]. Similarly, Allen and colleagues [39] estimated the median operating room charge at $1,970 for VATS versus $778 for thoracotomy. Miller [40] estimated that the total cost was $10,400 for VATS procedures versus $6,150 to $6,750 for thoracotomy; he concluded that at the present time, there is no procedure that can be done more cheaply by video-assisted thoracoscopy than by conventional open technique. Hidden costs include prolonged operating room time, VATS equipment, and disposable material, but also the increased cost of double-lumen catheter intubation, which is mandatory for VATS. The disposables are more expensive; most anesthesiologists perform bronchoscopy to check adequate position of the tube, and induction of anesthesia takes more time. Fear of missing blebs during thoracoscopy leads to a “high-tech” management including routine computed tomographic scan to obviate blebs [41]. To control the total cost, it seems reasonable to withhold computed tomographic scan in patients with primary spontaneous pneumothorax because it should not affect patients’ treatment [42]. The cost of expanded indications has never been alluded to [43]: some authors now advocate definite treatment at the first episode [5]. Cost of recurrence should also be considered; in addition, the psychologic impact of recurrence in patients who have undergone operation is inevaluable [44].
Randomized Trials Despite the relative frequency of spontaneous pneumothorax, there are only two controlled studies available to date. Both conclude there is relatively poor performance of VATS in comparison with open operation with limited incisions. Waller and colleagues [45] compared VATS and thoracotomy in a consecutive series of 60 patients, who were followed up for a median period of 15 to 16 months. All patients were treated by bleb resection and apical pleurectomy; thoracotomy was a limited posterolateral incision carried through the auscultatory triangle. Operative time was longer by 8 minutes in the VATS group (p , 0.01). There was no difference in morphine consumption, in duration of drainage, or in hospital stay. However, postoperative forced expiratory volume in 1 second was lower in the thoracotomy group. Kim and colleagues [46] have compared VATS and transaxillary minithoracotomy. Operative time, amount of analgesics, and chest tube drainage time were very similar. However, 4 of 30 patients managed with VATS did have recurrence. Kim and colleagues concluded that transaxillary minithoracotomy is the preferred approach owing to the lower cost and improved cosmetic result.
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Conclusions and Perspectives for Video-Assisted Thoracic Surgery The two final questions are the following: Should minimally invasive surgery allow for expanded indications? Considering its debatable reliability, is there any future for VATS in recurrent pneumothorax? When going through recent publications, there is an obvious shift of indications, because most teams perform an operation at the second episode. This seems reasonable, because the spontaneous recurrence rate is certainly in excess of 50%. Recent work also demonstrated that an air leak is unlikely to seal beyond 48 hours; operative management of persisting pneumothorax therefore may reasonably be performed at an earlier stage. In contrast, we consider excessive the suggestion that “VATS should be considered in patients with a first episode of idiopathic spontaneous pneumothorax, because these predominantly young patients may profit most from definitive therapy” [6]. Although thoracoscopy might immediately identify patients at risk for recurrence by disclosing blebs, there is no argument in favor of a correlation between thoracoscopic findings and patterns of recurrence [17]. Outside of large teaching hospitals, emergency thoracoscopy under local anesthesia is further limited by the availability of experienced and skilled physicians [19]. Schramel and colleagues [5] concluded that VATS should be performed for first episodes, by comparing total cost of conservative management and thoracoscopic management over two time periods. However, this study is biased because surgical patients of the historical control group underwent formal thoracotomy; when total hospitalization is taken into account, including “waiting time before VATS,” cost efficiency does not appear. We note that in a country like France, daily hospital charges double when comparing a medical ward with a surgical unit; even with similar duration of hospital stay, chest tube drainage in a medical ward reduces the cost by 50%. Besides, the 80% of patients who will not have recurrence are subjected to an unnecessary surgical procedure. Cole and colleagues [47] concluded that VATS should not be considered as the standard treatment of spontaneous pneumothorax: postoperative complications are similar to open procedures, but long-term results are less valuable. This conclusion is perhaps unfair when assigned to a definitive statement. Video-assisted thoracic surgery is an interesting tool for teaching hospitals, because the teacher can adequately follow the trainee. Video-assisted thoracic surgery is obviously less painful than a posterolateral or lateral thoracotomy. Videoassisted thoracic surgery has indirectly contributed to promote a cost-effective discharge policy. Increased experience should lead to improved results. In fine, surgical judgement, not a drive for novelty, must be used to compare thoracoscopic surgery with an open operation through a short axillary incision [48]. When cost is a problem, the transaxillary technique appears as a valuable alternative with anticipated equal immediate re-
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sults, and probably improved long-term results. Therefore, a large, controlled study comparing VATS and transaxillary approach is more than desirable.
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