Bilateral Video-Assisted Thoracoscopic Surgery for Bilateral Spontaneous Pneumothorax

doi:10.1378/chest.122.6.2234

Chest

Volume 122, Issue 6, December 2002, Pages 2234-2237

https://doi.org/10.1378/chest.122.6.2234 Get rights and content

Objective

To review our experience with bilateral video-assisted thoracoscopic surgery (VATS) for the treatment of bilateral spontaneous pneumothorax (SP).

Design

Retrospective study followed by a telephone interview for follow-up.

Setting

Thoracic Surgery Department, Chest Diseases Hospital, Kuwait.

Patient and interventions

Fifteen patients undergoing bilateral VATS for bilateral SP from 1994 to 1999.

Results

The mean age of the patients was 22.9 years (range, 17 to 34 years), and 14 were men. All patients were successfully treated using the bilateral video-assisted technique. Operative indications included simultaneous bilateral pneumothorax (n = 7) and contralateral recurrence of SP (n = 8). Twelve patients had primary SP. In the three remaining patients, simultaneous bilateral SP was secondary to sarcoidosis in two patients and histiocytosis X in one patient. Eleven patients had multiple blebs or bullae located in the upper lobes, and 4 patients had no blebs. All blebs or bullae were resected. All patients had gauze pleurodesis. The mean ± SD operative time was 133.6 ± 9.1 min. There were no perioperative complications and no deaths attributable to the procedure. Postoperative prolonged air leak occurred in three patients (20%). The mean drainage time was 3 days (range, 2 to 8 days). The mean postoperative hospital stay was 5 ± 1.7 days. Mean follow-up was 3.3 years (range, 2 to 5 years) for all patients. Pneumothorax recurred in one patient with histiocytosis X after 1 month and required a reoperation on the right side.

Conclusions

Bilateral VATS is a safe procedure in the treatment of simultaneous and nonsimultaneous bilateral SP. This avoids the need for subsequent operations.

Section snippets

Materials and Methods

The study was conducted at the Chest Diseases Hospital in Kuwait, which is the only center for the surgical treatment of chest diseases in Kuwait. From December 1994 to December 1999, 15 patients with bilateral simultaneous and nonsimultaneous SP were treated by bilateral VATS. Preoperative investigations included a chest radiograph, CBC count, serum electrolytes, and renal function tests. CT was done in three patients with secondary SP.

Results

The clinical data of the 15 patients with bilateral SP are summarized in Table 1. The mean age at operation was 22.9 ± 4 years (range, 17 to 34 years). The indications for operation are contralateral recurrence of SP in eight patients and simultaneous bilateral SP in seven patients. Twelve patients had primary SP. In the three remaining patients, simultaneous bilateral SP was secondary to sarcoidosis in two patients and histiocytosis X in one patient.

The operative time was 134 ± 9 min (range,

Discussion

Because of the frequently bilateral nature of bullous lesions of the lung, there is a risk of contralateral pneumothorax in patients with unilateral disease.¹ Studies have reported the rate of the first ipsilateral recurrence after first attack to be 21.8 to 45% in patients with primary SP.⁶^,⁷^,⁸ Contralateral recurrences have been reported in 5 to 15% of patients.¹^,⁶^,⁹ However, the risk of contralateral recurrence after unilateral operation have been reported in 18 to 50% of patients.¹^,²

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Cited by (43)

SPLF/SMFU/SRLF/SFAR/SFCTCV Guidelines for the management of patients with primary spontaneous pneumothorax: Endorsed by the French Speaking Society of Respiratory Diseases (SPLF), the French Society of Emergency Medicine (SFMU), the French Intensive Care Society (SRLF), the French Society of Anesthesia & Intensive Care Medicine (SFAR) and the French Society of Thoracic and Cardiovascular Surgery (SFCTCV)
2023, Respiratory Medicine and Research
Primary spontaneous pneumothorax (PSP) is the presence of air in the pleural space, occurring in the absence of trauma and known lung disease. Standardized expert guidelines on PSP are needed due to the variety of diagnostic methods, therapeutic strategies and medical and surgical disciplines involved in its management.
Literature review, analysis of literature according to the GRADE (Grading of Recommendation Assessment, Development and Evaluation) methodology; proposals for guidelines rated by experts, patients, and organizers to reach a consensus. Only expert opinions with strong agreement were selected.
A large PSP is defined as presence of a visible rim along the entire axillary line between the lung margin and the chest wall and ≥2 cm at the hilum level on frontal chest x-ray. The therapeutic strategy depends on the clinical presentation: emergency needle aspiration for tension PSP; in the absence of signs of severity: conservative management (small PSP), needle aspiration or chest tube drainage (large PSP). Outpatient treatment is possible if a dedicated outpatient care system is previously organized. Indications, surgical procedures and perioperative analgesia are detailed. Associated measures, including smoking cessation, are described.
These guidelines are a step towards PSP treatment and follow-up strategy optimization in France.
Guidelines for management of patients with primary spontaneous pneumothorax
2023, Revue des Maladies Respiratoires
Recommandations des sociétés d'experts sur la prise en charge du pneumothorax spontané primaire
2022, Revue des Maladies Respiratoires Actualites
Simultaneous bilateral thoracoscopic blebs excision reduces contralateral recurrence in patients undergoing operation for ipsilateral primary spontaneous pneumothorax
2020, Journal of Thoracic and Cardiovascular Surgery
Contralateral recurrence in patients with primary spontaneous pneumothorax is approximately 15%. If positive for blebs, the recurrence rate increases to 26%. This study seeks to determine whether simultaneous contralateral video-assisted thoracic surgery blebs excision would effectively lower the contralateral incidence of pneumothorax in patients undergoing surgery for ipsilateral primary spontaneous pneumothorax.
Between January 2009 and December 2015, 335 patients with primary spontaneous pneumothorax, surgically treated in a single institution, were retrospectively studied. The median follow-up was 75 (50-99) months. All patients received video-assisted thoracic surgery blebectomy/bullectomy with pleural abrasions. They were classified into 3 groups: (1) ipsilateral video-assisted thoracic surgery without contralateral blebs/bullae included 142 patients with ipsilateral primary spontaneous pneumothorax without contralateral blebs/bullae only receiving ipsilateral video-assisted thoracic surgery; (2) ipsilateral video-assisted thoracic surgery with contralateral blebs/bullae included 123 patients with ipsilateral primary spontaneous pneumothorax with contralateral blebs/bullae receiving only ipsilateral video-assisted thoracic surgery; and (3) bilateral video-assisted thoracic surgery with contralateral blebs/bullae included 70 patients with ipsilateral primary spontaneous pneumothorax with contralateral blebs/bullae receiving 1-stage bilateral video-assisted thoracic surgery. Demographic data, perioperative details, recurrence patterns, recurrence-free survivals, and risk factors were compared.
The percentage of contralateral recurrence for the ipsilateral video-assisted thoracic surgery without contralateral blebs/bullae, ipsilateral video-assisted thoracic surgery with contralateral blebs/bullae, and bilateral video-assisted thoracic surgery with contralateral blebs/bullae groups differed significantly (0.7%, 14.6%, and 2.9%, respectively; P = .002). Multivariate analysis using the Cox proportional hazard model revealed that age less than 18 years (hazard ratio, 2.71; 95% confidence interval, 1.14-6.44; P = .024) and ipsilateral video-assisted thoracic surgery with contralateral blebs/bullae (hazard ratio, 22.13, 95% confidence interval, 2.96-165, P = .003) were predictors of contralateral recurrence, of which recurrence-free survival was notably different among groups as determined by Kaplan–Meier analysis (P < .0001).
Simultaneous contralateral blebectomy in patients with primary spontaneous pneumothorax receiving ipsilateral video-assisted thoracic surgery significantly lowered future contralateral recurrence.
Risk factors predisposing to prolonged air leak after video-assisted thoracoscopic surgery for spontaneous pneumothorax
2014, Annals of Thoracic Surgery
Citation Excerpt :
In the age group 13 to 49 years, operative risk was scored as ASA-I in 99.6% of patients and as ASA-II in 0.4% of patients; in the age group 50 to 69 years, ASA-II accounted for 9.5% of patients and ASA-III accounted for 0.9% of patients; and in the age group 70 to 85 years, ASA-II and ASA-III accounted for 55.9% and 15.7% of patients, respectively. Patients undergoing bilateral procedures usually have good medical fitness without the above-mentioned variables, yet still had a higher PAL rate, from 16.5% to 20% [8, 9]. PAL may occur as a result of compromised pulmonary reexpansion and persistent residual space, because postoperative pain caused by bilateral thoracotomy and chest tube drainage adversely affect respiratory movement and effective expectoration and early ambulation.
The goal of this prospective study was to determine risk factors for prolonged air leak (PAL) for patients who underwent video-assisted thoracoscopic surgery (VATS) for spontaneous pneumothorax.
Between January 2002 and June 2012, a total of 2,292 patients were eligible for enrollment in the study: 1,800 patients had primary spontaneous pneumothorax and 492 patients had secondary spontaneous pneumothorax. There were 312 female and 1,980 male patients with a mean age of 41 years (range, 13 to 85 years). Twenty-three variables were recorded for each patient. The primary endpoint was rate of postoperative PAL (chest tube drainage for >7 days). Statistical evaluation used univariate and multivariate logistic regression analyses.
A total of 223 (9.73%) cases of postoperative PAL occurred in 2,292 patients. Comparing clinical characteristics between the patients with and without PAL, mean age in the air leak group (59 ± 18 y) was significantly older than that in non-air-leak group (39 ± 18 y) (p < 0.05). Multivariate analyses found 4 variables related to PAL (p < 0.05): age, American Society of Anesthesiologists scores, bilateral procedures, and bullae diameter. No significant relationships were found between pleural abrasions and/or talc pleurodesis and PAL.
Prolonged air leak is one of the most common complications after spontaneous pneumothorax operations. Age, American Society of Anesthesiologists scores, bilateral procedures, and bullae diameter were risk factors for PAL. Use of talc pleurodesis with pleural abrasion may not decrease the incidence of PAL in VATS spontaneous pneumothorax operation. Talc pleurodesis with pleural abrasion should be used cautiously in patients with significant comorbid conditions or advanced age.
Simultaneous occurrence of ipsilateral primary spontaneous hemopneumothorax and contralateral pneumothorax in an adolescent
2009, Journal of Pediatric Surgery
Citation Excerpt :
The primary spontaneous pneumothorax, which is defined as a pneumothorax without underlying lung disease, mostly occurs in young adolescent males and is usually caused by ruptured pleural blebs [5]. Primary spontaneous pneumothorax can occur bilaterally, either sequentially or simultaneously, in around 7.8% to 20% of patients surgically treated for PSP [1-3]. Patients with simultaneously bilateral PSP may deteriorate rapidly, and emergency drainage is recommended to eliminate the intrapleural air collection.
Primary spontaneous hemopneumothorax is a rare disorder but can be life-threatening secondary to massive bleeding. The authors encountered an uncommon case of left primary spontaneous hemopneumothorax and simultaneous right pneumothorax. After initial bilateral tube thoracostomies, successful 1-stage bilateral video-assisted thoracic surgery (VATS) was performed before the condition deteriorated or complications occurred. Active oozing from a ruptured vascularized bulla was identified at the apex of the left upper lobe. One-stage bilateral VATS appears to be a reasonable method of surgical intervention, but in patients under life-threatening clinical conditions, it may still be difficult to use this strategy, and a staged operation may be considered.

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Chest

Minimally Invasive TechniquesBilateral Video-Assisted Thoracoscopic Surgery for Bilateral Spontaneous Pneumothorax

Objective

Design

Setting

Patient and interventions

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Chest

Chest

Chest

Ann Thorac Surg

Chest

Minimally Invasive Techniques
Bilateral Video-Assisted Thoracoscopic Surgery for Bilateral Spontaneous Pneumothorax