Does video-assisted thoracoscopic pleurectomy result in better outcomes than open pleurectomy for primary spontaneous pneumothorax?

Wessex Cardiothoracic Centre, Department of Thoracic Surgery, Southampton University Hospitals NHS Trust, Southampton General Hospital, Tremona Road, Southampton, UK.
Interactive Cardiovascular and Thoracic Surgery (Impact Factor: 1.16). 03/2008; 7(4):673-7. DOI: 10.1510/icvts.2008.176081
Source: PubMed


The question addressed by a best evidence topic approach using a structured protocol was whether pleurectomy using video-assisted thoracoscopic surgery (VATS) resulted in better outcomes than open pleurectomy for primary spontaneous pneumothorax. Altogether 45 relevant papers were identified of which nine papers represented the best evidence to answer the question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that VATS pleurectomy has been shown to be comparable to open pleurectomy in the treatment of spontaneous pneumothorax, with a meta-analysis and several RCTs showing reductions in length of hospital stay and analgesic requirements. Postoperative pulmonary dysfunction has also been shown to be reduced after VATS pleurectomy in two RCTs, although a third study found no significant difference. A concern may be a four-fold increase in the recurrence of pneumothorax following VATS pleurectomy as compared to open pleurectomy reported in a recent meta-analysis of four randomised and 25 non-randomised studies performed in 2007 and published in the Lancet, although a second meta-analysis of only the randomised trials did not show this difference.

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    • "thoracoscopic procedures have been adopted. Meta-analyses comparing thoracotomy with video-assisted thoracoscopic surgery (VATS) procedures for treatment of pneumothorax have shown lower recurrence rates (1%) with open procedures [2] [3] but these are associated with greater blood loss, significantly greater postoperative pain and longer hospital stay [4]. Nowadays, VATS bullectomy and pleurodesis is widely accepted as a safe and reliable option for treatment of recurrent pneumothorax [1] [5] [6]. "
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    ABSTRACT: Over the past two decades, video-assisted thoracoscopic blebectomy and pleurodesis have been used as a safe and reliable option for treatment of spontaneous pneumothorax. The aim of this study is to evaluate the long-term outcome of video-assisted thoracoscopic surgery (VATS) treatment of spontaneous pneumothorax in young patients, and to identify risk factors for postoperative recurrence. We retrospectively analysed the outcome of VATS treatment of spontaneous pneumothorax in our institution in 150 consecutive young patients (age ≤40 years) in the years 1997-2010. Treatment consisted of stapling blebectomy and partial parietal pleurectomy. After excluding 16 patients lost to follow-up, in 134 cases [110 men, 24 women; mean age, 25 ± 7 standard deviation years; median follow-up, 79 months (range: 36-187 months)], we evaluated postoperative complications, focusing on pneumothorax recurrence, thoracic dysaesthesia and chronic chest pain. Risk factors for postoperative pneumothorax recurrence were analysed by logistic regression. Of 134 treated patients, 3 (2.2%) required early reoperation (2 for bleeding; 1 for persistent air leaks). Postoperative (90-day) mortality was nil. Ipsilateral pneumothorax recurred in 8 cases (6.0%) [median time of recurrence, 43 months (range: 1-71 months)]. At univariate analysis, the recurrence rate was significantly higher in women (4/24) than in men (4/110; P = 0.026) and in patients with >7-day postoperative air leaks (P = 0.021). Multivariate analysis confirmed that pneumothorax recurrence correlated independently with prolonged air leaks (P = 0.037) and with female gender (P = 0.045). Chronic chest wall dysaesthesia was reported by 13 patients (9.7%). In 3 patients, (2.2%) chronic thoracic pain (analogical score >4) was recorded, but only 1 patient required analgesics more than once a month. VATS blebectomy and parietal pleurectomy is a safe procedure for treatment of spontaneous pneumothorax in young patients, with a 6% long-term recurrence rate in our experience. Postoperative recurrence significantly correlates with female gender and with prolonged air leakage after surgery. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
    Interactive Cardiovascular and Thoracic Surgery 02/2015; 20(5). DOI:10.1093/icvts/ivv022 · 1.16 Impact Factor
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    • "However, re-operation following VATS is more often required than that after open thoracotomy (Tomasdottir et al., 2007), with a higher rate of both late recurrent pneumothoraces and prolonged early postoperative air-leakage. A four-fold increase in the recurrence of pneumothorax following VATS pleurectomy (as compared to open pleurectomy) has been reported in a meta-analysis with 4 randomized and 25 non-randomized studies (Barker et al., 2007), although a second meta-analysis of only the randomized trials did not show this difference (Vohra et al., 2008). VATS for PSP can be accomplished mostly through three ports, but two or single port(s) with the use of single incision port laparoscopic surgery (SILS) system has been reported in recent years (Jutley et al., 2005; Gigirey Castro et al., 2010). "
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    ABSTRACT: Primary spontaneous pneumothorax (PSP) commonly occurs in tall, thin, adolescent men. Though the pathogenesis of PSP has been gradually uncovered, there is still a lack of consensus in the diagnostic approach and treatment strategies for this disorder. Herein, the literature is reviewed concerning mechanisms and personal clinical experience with PSP. The chest computed tomography (CT) has been more commonly used than before to help understand the pathogenesis of PSP and plan further management strategies. The development of video-assisted thoracoscopic surgery (VATS) has changed the profiles of management strategies of PSP due to its minimal invasiveness and high effectiveness for patients with these diseases.
    Journal of Zhejiang University SCIENCE B 10/2010; 11(10):735-44. DOI:10.1631/jzus.B1000131 · 1.28 Impact Factor
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    ABSTRACT: Es gibt viele Möglichkeiten einen spontanen Pneumothorax zu behandeln. Dabei gelten zwei Grundsätze: 1. Beim symptomatischen Patienten muss die Luft aus dem Pleuraspalt entfernt werden und 2. sollte eine effektive Rezidivprophylaxe angeboten werden. Die einfachste und schonendste Möglichkeit bietet die einmalige Exsufflation (Aspiration), welche häufig erwähnt, aber paradoxerweise selten angewendet wird. Die Exsufflation ist beim erstmaligen primären idiopathischen Spontanpneumothorax Mittel der Wahl. Im Falle eines Rezidivs ist die internistische thorakoskopische Talkumpleurodese eine sichere und kosteneffektive Therapieoption. Der sog. „graduierte“ europäische Talk ist sicher und induziert keine respiratorische Insuffizienz oder ein ARDS („acute respiratory distress syndrome“). Es wird nach wie vor über die optimale Therapiemethodik, sei es die einfache internistische Thorakoskopie, die VATS oder die Thorakotomie, debattiert. Beim sekundären Pneumothorax muss eine effiziente Rezidivprophylaxe angeboten werden. Auch in diesem Fall sind die internistische thorakoskopische Talkpleurodese oder die VATS („video-assisted thoracic surgery“) sichere und kosteneffektive therapeutische Alternativen. There are many different approaches still subject to debate in the management of spontaneous pneumothorax. But everybody agrees on two therapeutic aims: first, the removal of air from the pleural cavity if necessary; and second, to prevent recurrences of pneumothorax. Simple aspiration has been proven to be very cost-effective but remains rarely applied in the usual clinical setting. In cases of a first episode of primary spontaneous pneumothorax (PSP) simple aspiration is the first therapeutic choice. In cases of recurrence of PSP, thoracoscopic talc poudrage is safe and very cost-effective. The graded talc currently used in Europe does not induce any acute respiratory distress syndrome (ARDS) as has now been clearly demonstrated. The choice between simple talcage by medical thoracoscopy, video-assisted thoracic surgery (VATS) or thoracotomy is still being debated. In cases of secondary spontaneous pneumothorax, some prevention of recurrence has to be offered to the patients. Talc pleurodesis by medical thoracoscopy or VATS are also safe and cost-effective provided good expertise of local medical teams is present. SchlüsselwörterPneumothorax-Pleurodese-Thorakoskopie-Talk KeywordsPneumothorax-Pleurodesis-Thoracoscopy-Talc
    Der Pneumologe 09/2010; 7(5):357-363. DOI:10.1007/s10405-009-0388-z
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