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THE EFFECT OF THORACOSCOPIC PLEURODESIS IN
PRIMARY SPONTANEOUS PNEUMOTHORAX
Abdumajidov Axrorjon Akramlon o’g’li
Background: The standard operative treatment of primary spontaneous
pneumothorax (PSP) is thoracoscopic wedge resection, but necessity of
pleurodesis still remains controversial. Nevertheless, pleural procedure after
wedge re- section such as pleurodesis has been performed in some patients who
need an extremely low recurrence rate. Materials and Methods: From January
2020 to July 2024, 207 patients who had undergone thoracoscopic wedge resection
and pleurodesis were enrolled in this study. All patients were divided into two
groups according to the methods of pleurodesis; apical parietal pleurectomy
(group A) and pleural abrasion (group B). The recurrence after surgery had been
checked by reviewing medical record through follow-up in ambulatory care clinic
or calling to the patients, directly until January 2024. Results: Of the 207 patients,
the recurrence rate of group A and B was 9.1% and 12.8%, respectively and there
was a significant difference (p=0.01, Cox’s proportional hazard model). There was
no significant difference in age, gender, smoking status, and div mass index
between two groups. Conclusion: This study suggests that the risk of recurrence
after surgery in PSP is significantly low in patients who underwent thoracoscopic
wedge resection with parietal pleurectomy than pleural abrasion.
Key words: 1. Pneumothorax
2.
Pleurectomy
3.
Thoracoscopy
Pleurodesis
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INTRODUCTION
Primary spontaneous pneumothorax (PSP) is a common disorder for thin or
tall young male [1] and is characterized by its absence of underlying disease in the
lung parenchyma and caused by the rupture of small blebs at the apex part of the
lung.
Based on the consensus of the American College of Chest Physicians, it
suggests that patients with the second occur- rence or persistent air leaks (
＞
4 days)
undergo surgery for PSP. And patients who are at risk (Scuba divers, divers, pi-
lots, etc.) are recommended to be operated promptly at their the first occurrence
[2,3]. The main purposes of surgical treatment are closure of the air leak and
prevention of re-
1Department of Thoracic and Cardiovascular Surgery, Pusan National
University Hospital, Pusan National University School of Medicine,
2Department of Emergency Medicine, Samsung Changwon Hospital,
Sungkyunkwan University School of Medicine
† This study was presented in the Asian Society for Cardiovascular and
Thoracic Surgeons-Association of Thoracic and Cardiovascular Surgeons of Asia
(ASCVTS-ATCSA) 2011 Phuket, Thailand.
Received: February 1, 2024, Revised: April 21, 2022, Accepted: May 7, 2024
Corresponding author: Yeong-Dae Kim, Department of Thoracic and
Cardiovascular Surgery, Pusan National University Hospital, Pusan National
University School of Medicine, 179 Gudeok-ro, Seo-gu, Busan 602-739, Korea
(Tel) 82-51-240-7267 (Fax) 82-51-243-9389 (E-mail) domini@pnu.edu The
Korean Society for Thoracic and Cardiovascular Surgery. 2024. All right reserved.
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This is an open access article distributed under the terms of the Creative
Commons
Attribution
Non-Commercial
License
(http://creative-
commons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use,
distribution, and reproduction in any medium, provided the original work is
properly cited.
Thoracoscopic Pleurodesis in Primary Spontaneous Pneumothorax
currence [4-6].
Video assisted thoracoscopic surgery is a generalized oper- ative treatment of
primary spontaneous pneumothorax which has the advantage of superiority in
cosmetics, decrease of postoperative pain, curtailment of admission period, and
quicker return to society [7-9]. Thoracoscopic bleb removal using automatic stapler
is generalized as a standard method in the operative treatment of PSP, but necessity
of pleurodesis still remains controversial [5,10]. Nevertheless, pleurodesis is
needed in treatment of PSP in some cases. So we inves- tigated methods of
pleurodesis which are used in our hospital to compare the efficacy of pleurodesis
for the risk of re- currence in patient with PSP.
MATERIALS AND METHODS
From January 2020 to July 2024, 207 patients who had un- dergone
thoracoscopic wedge resection and pleurodesis were enrolled in this study. The
data including age, gender, smok- ing status, div mass index (BMI), operative
indications, method of pleurodesis, operative time, hospitalization, re- currence
after surgery, and follow-up duration were reviewed retrospectively from medical
records. The recurrence after surgery had been checked by reviewing medical
record through follow-up in ambulatory care clinic until or calling the patients
directly January 2011. There was no follow-up loss.
1)
Operative technique
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The operation was performed by two surgeons in Department of Thoracic
Surgery of Pusan National University Hospital. The indications of operative
treatment were persis- tent air leak (
＞
5 days) in patients with first experience of
pneumothorax, recurrence more than twice in ipsilateral side, and contralateral
recurrence.
All surgeons of the department used a standardized vid- eo-thoracoscopic
technique. A 10-mm, 60° thoracoscope was introduced in the seventh intercostals
space on the mid axil- lary line through a 1 cm skin incision. Under visual control,
two additional incisions were performed at the third inter- costal space on the mid-
axillary line, and at the useful site, so as to introduce endoscopic forceps, and
stapling device.
After thorough inspection of the pleural cavity and the whole parenchymal
surface, resection of bullae or blebs was per- formed by endoscopic stapling device.
Pleurodesis was per- formed as two methods depend on surgeon’s preference: ap-
ical parietal pleurectomy (group A) and pleural abrasion (group B). Pleurectomy
was performed to remove all parietal pleura over the fifth intercostals space by
using Argon Bovie except some portions of mediastinum region [11], and pleural
abrasion was performed at the same location by brushing enough to cause petechia
using a gauge. One straight thoracic catheter (24Fr; Mallinckrodt Medical, Athlone,
Ireland) was placed through the incision of the seventh intercostals space on the
mid-axillary line. The chest tube was placed posteri- orly and superiorly under
visual control. The chest tube was connected to a water seal system with 20 cm
H2O suction.
2)
Postoperative care
All patients were extubated in the operating room and transferred to the
general ward. Chest X-ray was performed to confirm the position of the chest tube
and expansion of lung. Postoperative pain was controlled by means of in- tra-
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venous patient controlled anesthesia associated with non-steroidal anti-
inflammatory medications or opioid drugs. Daily chest X-ray was obtained from
each patient. Chest tube removal was performed when completely expanded lung
and absence of air leak and drainage less than 200 mL during 24 hours were
obtained. All patients were discharged the next day of the removal of chest tubes,
if a chest X-ray was normal.
3)
Statistics
The statistics were evaluated by using SPSS ver. 12.0 (SPSS Inc., Chicago,
IL, USA), and the recurrence rate be- tween two groups were compared by using
Kaplan-Meier method and Cox proportional hazard method.
RESULTS
Of 207 patients, 188 patients were male and the age was
21.5±6.4 (mean±standard deviation) years. No intraoperative death or major
complication occurred during or after the operation. No patient required conversion
to thoracotomy.
Up Huh, et al
Table 1. Patients characteristics
Characteristic Group A (n=121) Group B (n=86) p-value
Age (yr)
21.4±5.9 (15−38) 21.7±7.1 (15−38) 0.749
Sex (male:female) 112:9 76:10 0.335
Body mass index (kg/m2) 20.1±9.1 (14.04−24.62) 19.0±2.1 (15.19−26.49)
0.287Operation time (min)
103.5±31.1 (45−195)
95.8±40.8
(45−285) 0.127
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Hospitalization (day)
6.0±3.9 (2−32)
6.5±3.3 (3−19)
0.389
Follow-up duration (mo) 65.8±38.2 (median, 71.44)
39.8±24.5
(median, 18.87)
＜
0.001
Table 2. Recurrence rate (hazard ratio by Cox regression)
Recurrence rate (%) Hazard ratio p-value
Group A Group B
9.1
12.8
3.108 0.014
wedge resection such as pleurodesis has been performed in some patients who
need an extremely low recurrence rate.
The operative methods for pleurodesis include mechanical and chemical
pleurodesis, and pleurectomy. Pleurectomy is known to be highly effective to
prevent a recurrence in PSP [10]. In the past, it was performed through
posterolateral
Mean duration of postoperative thoracostomy tube drainage
and mean postoperative stay were 5.2 and 6.2 days, respectively. And the
follow-up duration was 55.0±35.5 months.
All patients were divided into two groups according to the methods of
pleurodesis: apical parietal pleurectomy (group A, n=121) and pleural abrasion
(group B, n=86). The age of group A and B was 21.4±5.9 and 21.7±7.1 years and
the gender (male:female) of group A and B was 112:9 and 76:10. The BMI of group
A and B was 20.1±9.1 and 19.0±2.1 kg/m2, respectively. There was no significant
difference in age, gender, and BMI between two groups. The operative time of
group A and B was 103.5±31 and 95.8±40.8 mi- nutes, respectively. The
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hospitalization after surgery of group A and B was 6.0±3.9 and 6.5±3.3 days,
respectively (Table 1). The recurrence rate of group A and B was 9.1% and 12.8%,
respectively and it showed a significant difference (Table 2).
DISCUSSION
After the video assisted thoracoscopic surgery was general- ized as a standard
method in the operative treatment of pri- mary spontaneous pneumothorax, the
process of bleb removal using automatic stapler became common. However, it
remains debatable whether pleurodesis is necessary and which techni- que is best
[5,10]. Nevertheless, pleural procedure after
thoracotomy or limited lateral thoracotomy and avoided due to cosmetic
problem, chest pain, and nerve injury caused by thoracotomy. With the application
of video-assisted thoraco- scopic surgery, apical parietal pleurectomy was not
operated frequently due to technical problem and long operative time [12,13].
However, according to the development of thoraco- scopic instrument and
technique, more complicated operations have been performed by video-assisted
thoracic surgery. Apical parietal pleurectomy with video assisted thoracoscopic
surgery has also been more easy procedure. As other various methods of operating
the pleurectomy are presented, surgeons could save time and prevent the risk of
recurrence [11,14]. In contrast, pleural abrasion is preferred with video-assisted
thor- acoscopic surgery because of its simple skill, faster operative time, and being
performed easily. But pleural abrasion did not show same prevention effect for the
recurrence compared to pleurectomy [14-16]. Surgical chemical pleurodesis using
Talc remains rarely performed, because difficult next thoracic surgery due to severe
adhesion, the pain, and the possibility of carcinogenesis itself [17].
There was no significant difference of air leak in the post- operative
complication between apical parietal pleurectomy (group A) and pleural abrasion
(group B). The air leak means that lung is not completely expanded and the pleural
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adhesion is not properly induced. Therefore, it is important to make sure the
complete closure of air leak, primarily.
In 2010, Kim et al. [18] reported that apical pleurectomy
Thoracoscopic Pleurodesis in Primary Spontaneous Pneumothorax
was no more advantageous than mechanical pleural abrasion in terms of
operative time, postoperative course, and pre- vention of recurrent pneumothorax,
so complete resection of bullae and existence of residual bullae are more important
factors in reducing the incidence of recurrent pneumothorax than pleural
symphysis. However, results of our study present that the rate of recurrence of
group A and B was 9.1% and 12.8%, respectively and there was a significant
difference (p=0.014, hazard ratio=3.108) and suggest that the apical pa- rietal
pleurectomy could reduce the risk of recurrence. But these two studies have
different number of patients (87 vs. 207) and follow up duration (31.7±25.3 vs.
55.0±35.5 months).
CONCLUSION
This study suggests that the risk of recurrence after surgery in PSP is
significantly low in patients who underwent thor- acoscopic wedge resection with
parietal pleurectomy than pleural abrasion. However, prospectively randomized
clinical study will be required to clarify a clinical efficacy of apical parietal
pleurectomy.
ACKNOWLEDGMENTS
This work was supported by a 2-Year Research Grant of Pusan National
University.
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