Efficacy Study of Video-Assisted ThoracoscopicSurgery Pleurodesis for Spontaneous PneumothoraxPatrick Chan, MBBS, Peter Clarke, FRACS, Freddy J. Daniel, FRACS,Simon R. Knight, FRACS, and Siven Seevanayagam, FRACSThoracic Surgical Unit, Austin & Repatriation Medical Centre, Heidelberg, Victoria, Australia

Background. This study aims to assess the efficacy ofvideo-assisted thoracoscopic surgery pleurodesis in thetreatment of spontaneous pneumothorax with particularreference to the rate of recurrence after abrasion pleu-rodesis and postoperative neuralgia.

Methods. One hundred one patients who underwent109 video-assisted thoracoscopic surgery pleurodesis pro-cedures in the Austin & Repatriation Medical Centrebetween January 1992 and June 1998 were identified froma computerized database. The follow-up period was from8 months to 7 years and 1 month (mean, 44.4 months).Patients were telephoned and asked as to whether recur-rence occurred, and if so, when it occurred and how itwas treated. They were asked to grade their current painlevel from 0 to 6.

Results. Eighty-two patients were contacted, corre-sponding to 88 video-assisted thoracoscopic surgerypleurodesis procedures that were followed up (80.7%).There were five recurrences (5.7%). The pain level wasrated as 0 in 64 cases (72.7%), 1 in 27 cases (23.9%), 2 in 1case (1.1%), and 3 in 2 cases (2.3%).

Conclusions. These data suggest that video-assistedthoracoscopic surgery pleurodesis is a valid alternative tothoracotomy with pleurectomy for treatment of sponta-neous pneumothorax with an acceptable recurrence rateand minimal amount of postoperative neuralgia.

(Ann Thorac Surg 2001;71:452–4)© 2001 by The Society of Thoracic Surgeons

Spontaneous pneumothorax most commonly occurs intall, young, lean males and particularly in those who

smoke [1–5]. It occurs after rupture of blebs, whichgenerally occur at the apices of the upper lobes. Althoughthe condition is rarely life-threatening, it does account forsignificant time off from work and hospitalization in anotherwise healthy patient group [6].

Pneumothorax has a tendency for recurrences (20%after first episode, 60% after second episode, and 80%after third episode) [7–14]. The first episode, if uncompli-cated, is usually managed conservatively with intercostalcatheter, analgesia, and observation. However, with eachrecurrence, it is more likely there will be further recur-rent episodes, and, traditionally, definitive treatmentconsisting of thoracotomy, excision of the blebs, and apleurodesis has been offered [11, 15–18]. Unfortunately,the high instance of postoperative neuralgia resulted inreluctance among physicians to refer patients for opera-tive treatment until there had been several recurrences,compounding the overall morbidity.

The recent introduction of video-assisted thoraco-scopic surgery (VATS) techniques for the performance ofthe procedure, and also the change from a pleurectomyto an ablation pleurodesis, has rekindled the interest inearly definitive treatment with a significant reduction inoverall morbidity and time lost from work. The studyaims to establish the rate of postoperative neuralgia andthe recurrence rate after VATS pleurodesis.

Material and Methods

A cohort of 101 consecutive patients was identified fromthe computerized database of the thoracic surgical unit atthe Austin & Repatriation Medical Centre. These patientshad 109 VATS pleurodeses performed between January1992 and June 1998. Patients more than 50 years of agewere deliberately excluded so as to avoid patients withsecondary pneumothorax from emphysema that is usu-ally caused by rupture of a bulla.

Before the selected cohort there had been a great dealof variation in our technique as we switched from apleurodesis through a transaxillary thoracotomy to onedone purely by a VATS technique. The indications foroperation included all patients having unilateral recur-rence, and patients at initial presentation if there was acontinuous air leak for more than 4 days, a total ortension pneumothorax, or a previous history of a pneu-mothorax on the contralateral side.

All the patients were then followed by telephone andconsent obtained for their participation in the survey. Theywere asked questions from a standard questionnaire thatinclude whether a recurrence occurred, when it happened,and how it was treated. They were then asked to grade theircurrent pain level on a pain score from 0 to 6, whereby 0 ispain free; 1 is occasional discomfort; 2 is occasional use ofanalgesics; 3 is using nonopiate analgesics; 4 is regular painusing opiates; 5 is severe continuous pain; and 6 is incapac-itated. The standard 1 to 10 visual analog scale for paincould not be used easily over the telephone, and a descrip-tive 0 to 6 scale proved more appropriate.

The operation was performed in a standard fashion

Accepted for publication Sept 22, 2000.

Address reprint requests to Prof Clarke, 55 Victoria Parade, Fitzroy,Victoria 3065, Australia; e-mail: clarkecp@bigpond.net.au.

© 2001 by The Society of Thoracic Surgeons 0003-4975/01/$20.00Published by Elsevier Science Inc PII S0003-4975(00)02446-2

under general anesthesia using intubation with a double-lumen endotracheal tube. The patients were then placedin a lateral decubitus position, and the ipsilateral lungwas deflated.

A three-port approach was used incorporating the siteof an intercostal tube if this had been placed in the axillausing modified Hassan cannulas or disposable Endopathcannulas (Ethicon Endo-Surgery Inc, Cincinnati, OH).When bullae were identified they were ligated with aSurgilie (United States Surgical Corporation, Norwalk,CT) or resected with an endo stapler. If the only abnor-mality was apical scarring, this area was excluded usingan endo stapler without the knife.

The parietal pleura was abraded with a piece of Marlexmesh or strip of a diathermy scratch pad followed byinstillation of 100 mL of alcohol iodine. Apical and basalintercostal catheters were left through the anterior andlowermost port sites, and gentle suction was usedpostoperatively.

Results

Eighty-two of the 101 patients were successfully con-tacted. Four of them had bilateral VATS pleurodesis. Onepatient had 3 operations, having a VATS procedure oneach side and a recurrence managed by a thoracotomy.This gave a total of 88 VATS cases being followed up,corresponding to an 80.7% follow-up rate.

There were 57 men and 31 women, and their agesranged from 15 to 45 years. The mean age of the patientswas 27 years. Fifty of the operations were performed onthe right side and 38 on the left. Three of the VATSprocedures were converted to open thoracotomy becauseof technical reasons. These were included in the analysisas a VATS procedure had been proposed.

The follow-up period as of February 1999 ranged from8 months to 7 years and 1 month, with a mean follow-upof 44.4 months. There was a total of 5 recurrences,equivalent to 5.7% recurrence rate. Two of these were onthe left side and 3 on the right side. The recurrencesoccurred at 2, 6, 9, 14, and 21 months after the initialoperation (Fig 1).

The management of these recurrent pneumothoracesvaried. Two of them were only observed, and 2 patientsunderwent repeat VATS pleurodeses and had no furtherproblems. Only 1 patient required a minithoracotomyand pleurectomy.

The rating of postoperative neuralgia on the standardpain score showed that 64 patients (72.7%) had no pain atall (pain score of 0). Twenty-seven patients (23.9%) hadoccasional discomfort but did not require any analgesia(pain level of 1). One patient (1.1%) used occasionalnonopiate analgesia for discomfort. Only 2 patients(2.3%) required frequent nonopiates. Importantly, noneof the patients contacted required anything stronger thannonopiate analgesia.

Comment

The management of spontaneous pneumothorax hasalways been a dilemma for the clinician as although it israrely life-threatening, it affects an otherwise healthy

population, leading to a waste of hospital beds anddisruption of their working life. Conservative manage-ment for recurrent cases is inappropriate as furtherrecurrences are likely, but referring physicians have beenreluctant to refer patients for a thoracotomy because ofthe high instance of postoperative neuralgia.

Gaensler [17] originally popularized the complete pa-rietal pleurectomy in 1956 to obtain a pleurodesis. Thistechnique certainly has the best chance of obtaining apermanent pleurodesis but at an increased risk of neu-ralgia because of damage to intercostal nerves both second-ary to the need to spread ribs and from direct damage atpleurectomy. It also makes further thoracic operationsextremely difficult should any of these young patientsrequire thoracic surgical intervention in future years.

For these reasons, ablation pleurodesis was recom-mended by Clagett in 1968 [19]. Initially this procedurewas performed through a full posterolateral thoracot-omy, but more recently the transaxillary approach hasbeen the one of choice as advocated by Deslauries andcolleagues [16]. Although this latter approach gives abetter cosmetic result, there is little difference in postop-erative neuralgia rate, which is largely related to the needto spread the rib with pressure, traction on the associatedintercostal nerves, and disruption of the costotransversejoints [20–24]. Both approaches are followed by signifi-cant prolonged intercostal neuralgia [25].

Video-assisted thoracoscopic surgery was first used totreat pneumothorax in 1990 by Levi and associates [26].The following years saw further refinement in the tech-nique [27–30]. Several subsequent publications con-firmed the feasibility of the method with low recurrencerate, pleasing cosmetic result, and a much lower inci-dence of postoperative neuralgia. However, the long-term efficacy of the method and its postoperative neural-gia rate remain questionable owing to the limited periodof follow-up in these studies.

The long-term follow-up of patients with spontaneouspneumothorax is notoriously difficult as they are mostly

Fig 1. Actuarial freedom from recurrent pneumothorax after video-assisted thoracoscopic surgery pleurodesis.

453Ann Thorac Surg CHAN ET AL2001;71:452–4 EFFICACY OF VATS PLEURODESIS

young, fit, and highly mobile. The longer the term offollow-up, the more likely there will be missing patients.Yet, in our series with a mean follow-up period of 44months, a recurrence was noted as late as 21 months afterthe operation. Therefore, a longer follow-up period islikely to have a lower follow-up rate but would be closerto a true recurrence rate. Our overall recurrence rate of5.7% and follow-up rate of 80.7% with a follow-up periodof 44 months compares favorably with most other pub-lished series, which have relatively short periods offollow-up [25, 31–33].

Certainly, the recurrence rate of our VATS pleurodesisis slightly higher than after pleurectomy (0% to 5%) [9, 16,34] but this has been accepted as it is likely a number ofthese patients will require a thoracotomy in later life.This is a much more practical proposition with intact butfused pleura rather than having the lung directly adher-ent to the chest wall.

Similarly we have eschewed the use of talc in youngerpatients, although this gives an excellent pleurodesis, asthe talc remains in the eschar and there is a long-termrisk of developing a malignancy.

Significantly, the low instance of postoperative intercostalneuralgia of 3.4% is particularly gratifying, especially asnone of them required anything stronger than nonopiateanalgesia. Mouroux and associates [32] reported a similarrate of neuralgia at 3%. This is significantly lower thanpostoperative neuralgia rate after thoracotomy [32].

Our results of an acceptable recurrence rate and agratifyingly low incidence of postoperative neuralgiareinforces our belief that a VATS ablation pleurodesis isthe procedure of choice for patients with recurrent spon-taneous pneumothorax, complicated pneumothorax, orpersistent air leak. It should therefore be offered early inthe course of the disease to reduce time off from workand periods of hospitalization.

Once a pleurodesis has been performed, there is areduced likelihood of readmission for recurrence, and airleaks persisting for 4 days commonly go on for 10 to 14days. Patients who initially present with a total or tensionpneumothorax generally have a similar pattern if theyrecur, necessitating a further admission with an intercos-tal catheter rather than simple aspiration.

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