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Is it a myth to perform blind apical wedge resection in primary spontaneous pneumothorax surgery to improve recurrence rates?
Mustafa Vayvada1, Yelda Tezel2, Çağatay Tezel3
1 Department of Thoracic Surgery, Kartal Kosuyolu Training and Research Hospital, Istanbul, Turkey
2 Department of Chest Diseases, Sultan Abdulhamid Han Training and Research Hospital, Istanbul, Turkey
3 Department of Thoracic Surgery, Sultan Abdulhamid Han Training and Research Hospital, Istanbul, Turkey
|Date of Submission||18-Oct-2020|
|Date of Decision||20-Jan-2021|
|Date of Acceptance||05-Mar-2021|
|Date of Web Publication||09-Apr-2021|
Department of Thoracic Surgery, Kartal Kosuyolu Training and Research Hospital, K Blok Cevizli, Kartal, Istanbul
Source of Support: None, Conflict of Interest: None
Background: Video-assisted thoracoscopy surgery (VATS) is the first method for the surgical treatment of primary spontaneous pneumothorax (PSP). Many surgeons traditionally performed bullectomy or wedge resection (WR) in addition to mechanical or chemical pleurodesis. Our study aimed to determine whether WR was necessary without seeing bleb or bullae during the surgery.
Methods: Patients with no bleb or bullae detected during surgery were included in the study. Apical pleurectomy was performed in all cases. The patients were divided into two groups as WR and non-WR. The minimum follow-up period was 24 months. Medical records of patients were evaluated retrospectively. Patients who could not be followed up were excluded from the study.
Results: A total of 104 surgical treatments of PSP were performed, WR was not performed in 70 cases (67.3%). The surgical time was statistically significantly longer in the WR group than in the non-WR group. There was no statistically significant difference between the two groups in terms of drainage amount, drain removal time, length of hospital stay and bleeding requiring thoracotomy. Prolonged air leak was more common in the non-WR group than in the WR group (7.1% vs. 2.9%; P = 0.661). There was no difference in the rate of recurrence in either group. Recurrence was 2.9% (1/34) in the WR group and 2.9% (2/70) in the non-WR group.
Conclusion: In VATS of PSP, blind apical WR without bleb or bullae reduced prolonged air leakage but did not contribute to lowering the rate of pneumothorax recurrence.
Keywords: Apical wedge resection, primary spontaneous pneumothorax, recurrence rates
|How to cite this URL:|
Vayvada M, Tezel Y, Tezel &. Is it a myth to perform blind apical wedge resection in primary spontaneous pneumothorax surgery to improve recurrence rates?. J Min Access Surg [Epub ahead of print] [cited 2021 Dec 9]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=313459
| ¤ Introduction|| |
Pneumothorax can develop spontaneously, traumatically and iatrogenically. Spontaneous pneumothorax is divided into as primary and secondary. The incidence of spontaneous pneumothorax is 18–28/100,000 for men and 1.2–6/100,000 for women. The incidence of primary spontaneous pneumothorax (PSP) is 7.4/100,000 for men and 1.2/100,000 for women. The male/female ratio is 6.2/1 in PSP. PSP is more common in those aged 20–30 years, it is rare after age 40 years. The probability of pneumothorax recurrence for the second time varies between 40% and 60%, and this rate reaches 80% for the third episode. PSP occurs in healthy individuals who have no additional lung disease, usually by air passage from the alveolus to the pleural space caused by emphysema-like changes in the lung apex.
It is globally accepted that the first method to be chosen surgically for the treatment of PSP is video-assisted thoracoscopic surgery (VATS)., The treatment of surgery for PSP is performed due to prolonged air leak, bilateral pneumothorax, recurrent pneumothorax and in occupations such a such as pilot, diver and sailor. There is no consensus on which surgical technique should be used in PSP treatment (e.g., pleural abrasion, pleurectomy, wedge resection [WR] and chemical pleurodesis). Many surgeons perform bullectomy or WR in addition to mechanical or chemical pleurodesis. The purpose of performing pleurodesis is to reduce the rate of recurrence of pneumothorax by creating adhesion between two pleural leaves. Apical WR is a very common surgical procedure to provide apical adhesion even if bullae are not detected.
The aim of this study was to determine the effect of performing blind apical WR during VATS on pneumothorax recurrence for PSP.
| ¤ Methods|| |
One hundred and four patients without bullae or bleb in the lung parenchyma were included in the study between 2007 and 2012. Two types of surgical techniques were examined. The first group underwent pleural pleurectomy with WR (WR; n = 34), and the second group received isolated pleural pleurectomy (non-WR; n = 70).
Patients with no history of trauma or evidence of lung disease in their history and clinical/radiologic findings were considered as having PSP. Age, sex, surgical indication, whether WR was performed, drain withdrawal time, length of hospital stay, surgical time, follow-up time and presence of complications were recorded. The minimum follow-up period was 24 months. The patients who developed recurrence contacted by telephone and their hospital records were examined. Patients who could not be followed up were excluded from the study. Surgical indications were recurrence pneumothorax, bilateral pneumothorax, contralateral pneumothorax and prolonged air leak more than 7 days after tube thoracostomy.
Surgical intervention was recommended to all patients presenting with a second episode. Tube thoracostomy and closed underwater drainage were performed on patients who did not accept surgical intervention, had respiratory distress, hypoxia or could not undergo surgery for any reason within 24 h. Nasal O2 treatment at 2–3 L/min was given to patients whose surgery was planned. Before the surgery, haemogram, routine biochemistry and full urine tests were performed for all patients. Bleeding clotting times were measured. Electrocardiography, posteroanterior chest radiography and thorax computed tomography (CT) were taken.
All patients were intubated with a double-lumen endotracheal tube and placed in the lateral decubitus position. All surgeons used standard videothoracoscopic instruments and techniques. For optical observation, the camera port hole was opened by crossing the floors through a 1-cm incision through the middle axillary line in the seventh intercostal space. After the thoracic cavity and parenchymal structure were explored, a second port hole of 2 cm from the fourth or fifth intercostal space was opened. If there were adhesions between the lung and the chest wall, they were released using blunt and sharp dissections. Primarily, all lobes and pleural surfaces of the lung, especially the apex and lower lobe of the upper lung, were evaluated for bleb and bullae. Blebs and bullae that were smaller than 2 cm were treated by ligation and cauterisation using an endo grasper. A curved vascular clamp was placed below the bleb or bullae, which was pulled close to the utility incision and ligatured by hand. Bullae that were larger than 2 cm were excised using the endoscopic stapler. Pleurectomy was limited to only the parietal pleura. The mediastinal and diaphragmatic pleura was not touched, and phrenic nerve and diaphragmatic motility were preserved. The entire parietal pleura was peeled from at least the fifth intercostal space. The limits of the planned pleurectomy were determined by drawing lines parallel to the vertebral column from the posterior to the internal mammary veins from the anterior. These lines are combined in the apex. The parietal pleura was held at the top junction using thoracoscopic forceps and was separated from the thoracic wall with blunt dissection. The created pleural flap was dissected up to the entrance of the camera port and excised.
After the surgery was completed, the lung was inflated with 30 mm Hg pressure to check whether the lung filled the rib cage and for air leakage. One apical 24-F or 28-F drain was placed in the pleural cavity. The parenchyma and pleura were taken to the pathology laboratory for histologic examination.
All patients were extubated in the operating room. Hourly drainage was monitored on the first post-operative day. Pain control was achieved with intravenous opiates. All patients were followed up through daily chest radiography. The thorax drain was removed in the absence of air leakage at 24-h follow-up, 200 mL below the drainage, and expansion on chest X-ray. The patients were discharged the day after the drain was removed or the next day. The presence of air leakage lasting longer than 7 days after the surgery was evaluated as prolonged air leakage.
| ¤ Results|| |
One hundred and twelve patients underwent VATS with the diagnosis of PSP in the study period. Eight patients who were five patients in the WR group and three in the non-WR group were lost to follow-up. A total of 104 patients were included in this study. Ninety-six (92.3%) were male and eight (7.7%) were female. The median age was 25 (range, 15–44) years. The intervention was performed on the right side in 68 (65.4%) patients and on the left side in 36 (34.6%) patients. Indications for surgical intervention were ipsilateral recurrent pneumothorax (n = 84, 80.8%), prolonged air leak (n = 14, 13.5%), contralateral pneumothorax (n = 4, 3.8%) and bilateral pneumothorax (n = 2, 2.8%).
The age and sex distribution were similar in both the groups. There were more right-sided operations in the WR group than in the non-WR group (76.5% vs. 60%). Two (5.9%) patients had a surgical indication of prolonged air leakage in the WR group compared with 12 (17.2%) in the non-WR group. Ipsilateral recurrence and contralateral pneumothorax were surgical indications for 29 patients and three patients in the WR group and 55 and one patient in the non-WR group, respectively. Bilateral pneumothorax was the indication in two patients in the non-WR group [Table 1].
Surgical time in the WR group was statistically significantly longer than in the non-WR group (90 min vs. 86.5 min, P = 0.012). There was no statistically significant difference between drain indwelling time, length of hospital stay, drainage amount and haemorrhage in either group. The rate of prolonged air leakage after surgery was 7.1% (5/70) in the non-WR group and 2.9% (1/34) in the WR group (P = 0.661). However, the risk of developing recurrence in both groups was similar (2.9% vs. 2.9; P = 0.999). The overall recurrence rate was 2.9% (3/104). The recurrence rate was the same in both the groups (2.9% vs. 2.9%) [Table 2].
| ¤ Discussion|| |
The purpose of routine WR is to remove blebs that cannot be detected intraoperatively, as well as to provide apical adhesion. In our series, the rate of prolonged air leakage after surgery was 7.1% (5/70) and the recurrence rate was 2.9% (2/70) in the WR group. The non-WR group had a higher prolonged air leakage rate than the WR group, but had an equal recurrence rate. A recurrence rate of 2.9% (1/34) is acceptable based on the results in the literature.,,, Many authors recommended pleural abrasion instead of pleurectomy, indicating that pleurectomy was a much aggressive method due to post-operative bleeding. Rena et al. reported that the rate of post-operative haemorrhage after pleurectomy was 7.4%. In our study, we observed a low recurrence rate in patients who underwent pleurectomy (1.9%, 2/104).,
In the study by Czerny et al., recurrence was not observed in patients who underwent pleurectomy + WR, whereas the recurrence rate was 7% (4/57) in patients who underwent pleurectomy only. In our study, WR in addition to pleurectomy did not affect the recurrence rate. The recurrence rate in patients without WR was 2.8% (2/70). The low recurrence rate me be as a result of the development in VATS techniques and materials.
The purpose of PSP treatment is to end the air leakage and prevent recurrence of the disease. Free air formation in the pleural cavity should be prevented by providing diffuse adhesions between the parietal pleura and visceral pleura. It remains controversial as to which method should be used in surgical treatment (pleurectomy ± pleural abrasion ± bullectomy ± chemical pleurodesis). A multi-centre study showed that pleurodesis had no effect on relapse. Talc is the most commonly used chemical agent in pleurodesis. Talc deposits form on the mediastinum, mediastinal pleura, pericardium, lung and liver as a result of pleurodesis with talc. At the same time, talc causes an inflammatory reaction in both the parenchyma and pleura, and prepares the ground for pleural thickening. Pulmonary compliance decreases with pleural thickening and may cause restrictive respiratory disorders. For this reason, talc is not used in our clinic in PSP treatment, which is a benign disease. Talc pleurodesis used in young patients complicates possible lung resection and lung transplant procedures in the future.
Many authors recommend bullae and bleb resection in the surgical treatment of pneumothorax, and blind apical WR even if no apical lesion is seen. PSP usually occurs with the rupture of the apical bullae or bleb. Although many mechanisms have been discussed, the general consensus is that subpleural blebs occur when the alveolar is exposed to high mean swelling pressure over an extended period of time. These blebs can tear because pleural pressure is more negative in the apex, and cause pneumothorax. The purpose of routine WR is to remove blebs that cannot be detected intraoperatively, as well as to provide apical adhesion.
Subpleural blebs and bullae are defined as emphysema-like changes. It is seen in 67%–71% of patients with PSP at the time of surgery. Blebs can be seen even in non-smoking patients with PSP. In 85% of patients with PSP, emphysema-like changes are detected in the chest CT. However, there was no correlation between these changes and the recurrence of pneumothorax. Although emphysema-like changes are the strongest cause of PSP, this cannot be seen during surgery, and leakage from different regions in tests for air leakage suggests the presence of pleural pores. The excess rate of recurrence in bullae or bleb excisions without mechanical pleurodesis can be explained by this situation.
Post-operative air leakage is defined as air escaping from the lung parenchyma to the pleural cavity after any surgery in the thoracic cavity. The air leak usually ends within the first 3 days after the lung is completely swollen and fills the gap between the lung and chest wall. Prolonged air leakage lasts more than 7 days. In order to prevent prolonged air leakage, caution should be exercised when adhesions are removed, the lung tissue is caught, and when fissures are dissected during surgery. In addition, if the surgical intervention will be performed on the parenchymal tissue, supportive materials should be used. Prolonged hospital stay, costs, complications, development of empyema and deterioration of ventilation are the consequences of prolonged air leakage. In our study, although prolonged air leakage was more common in patients who did not undergo apical WR, there were no complications or reoperation. It may be thought that emphysema-like changes that are not visible during surgery may be the reason for air leakage. The authors who advocate the necessity for apical WR stated that the aim was to provide apical adhesion.,,,,, According to our study, apical WR did not contribute to the recurrence rate; therefore it may be concluded that WR is not necessary to provide apical adhesion. Surgical removal of emphysema-like changes, which are mostly apical, should be the main subject of discussion. PSP pathophysiology and management is still under investigation and will continue to be discussed.
| ¤ Conclusion|| |
Surgical techniques will vary according to the patient and surgeon and will continue to be compared. Blind apical WR without blebs or bullae detected during surgery did not contribute to lowering the rate of pneumothorax recurrence but decreased prolonged air leakage.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]