Efficacy of Blebs Detection for Preventive Surgery in Children’s Idiopathic Spontaneous Pneumothorax
Hôpital Armand Trousseau Université Pierre et Marie Curie-Paris 6 Paris France World Journal of Surgery
(Impact Factor: 2.64).
01/2010; 34(1):185-189. DOI: 10.1007/s00268-009-0286-x
This retrospective, single-center study was designed to assess our management strategy based on blebs detection on the initial CT scan.
Children younger than aged 18 years presenting with a primary spontaneous pneumothorax (PSP) between 2000 and 2007 in a University Children’s Hospital (hospital Armand Trousseau, Paris, France) were included in this study.
Twenty-five children who presented with PSP were included. The mean age was 14.2 ± 1.9 years, and the sex ratio was 2.1. There was no significant difference between patients with or without blebs with regard to the anthropomorphic data or the side of the pneumothorax. Six patients had recurrence, which, in most cases, was a grade 1 pneumothorax. Fourteen (56%) children showed blebs on CT scan, which was ipsilateral or bilateral in 13 cases and contralateral in 1 case. Eleven of these children had surgery, and all the remaining patients (n = 3) had recurrence. All the patients, except one, presenting blebs on the preoperating CT scan, showed blebs on the subsequent surgery (predictive positive value = 92%), and the CT-scan sensibility for blebs was 75%.
In children, blebs detection on CT scan has a good sensitivity and may be a useful tool to determine the indication of lung surgery to prevent PSP recurrence.
Available from: PubMed Central
- "Figure 1 shows a general outline of our novel early diagnostic method. In the future, the algorithm may be real time coupled with either ultrasound or CT scan data to quantify patient risk of pneumothorax earlier and improve the current diagnostic benchmark of only 75% lesion sensibility . Unlike competitive diagnostic procedures for pneumothorax such as infrared thermography , our proposed method relies on detecting pathological hallmarks in tissue behavior before acute lung collapse actually occurs. "
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ABSTRACT: Spontaneous pneumothorax, a prevalent medical challenge in most trauma cases, is a form of sudden lung collapse closely associated with risk factors such as lung cancer and emphysema. Our work seeks to explore and quantify the currently unknown pathological factors underlying lesion rupture in pneumothorax through biomechanical modeling. We hypothesized that lesion instability is closely associated with elastodynamic strain of the pleural membrane from pulsatile air flow and collagen-elastin dynamics. Based on the principles of continuum mechanics and fluid-structure interaction, our proposed model coupled isotropic tissue deformation with pressure from pulsatile air motion and the pleural fluid. Next, we derived mathematical instability criteria for our ordinary differential equation system and then translated these mathematical instabilities to physically relevant structural instabilities via the incorporation of a finite energy limiter. The introduction of novel biomechanical descriptions for collagen-elastin dynamics allowed us to demonstrate that changes in the protein structure can lead to a transition from stable to unstable domains in the material parameter space for a general lesion. This result allowed us to create a novel streamlined algorithm for detecting material instabilities in transient lung CT scan data via analyzing deformations in a local tissue boundary.
Available from: Shawn D St. Peter
- "This makes a strong argument for not using CT in the management of these patients because the blebs not only are apparently difficult to find on CT but also don't necessarily predict outcome when found. In a recent small series of 14 children who underwent CT for bleb detection, the authors felt CT was useful because most of the patients with blebs identified on CT were found to have bullous disease during thoracoscopy . This corroborated the result of a previous series of 43 children in which there were no false positives . "
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ABSTRACT: Spontaneous pneumothorax may result from rupture of subpleural blebs. Computed tomography (CT) has been used to identify blebs to serve as an indication for thoracoscopy. We reviewed our experience with spontaneous pneumothorax to assess the utility of CT in these patients.
A retrospective review was conducted of all patients who underwent an operation for spontaneous pneumothorax from January 1999 to October 2009. All procedures were performed thoracoscopically.
We identified 39 pneumothoraces in 34 patients who underwent evaluation and a procedure for spontaneous pneumothorax. Mean age was 16.1 years (range, 10-23 years), with an average of 1.7 spontaneous pneumothoraces before operation (range, 1-4). Preoperative chest CT scans were obtained in 26 cases. Blebs were demonstrated on 8 CT scans. The presence of blebs was confirmed at operation in all 8 patients. Of the 18 negative scans, 14 (77.8%) were found to have blebs intraoperatively, 7 of these patients were initially managed nonoperatively and developed recurrence. The sensitivity of CT for identifying blebs was 36%.
Chest CT does not appear to be precise in the identification of pleural blebs and a negative examination does not predict freedom from recurrence. Operative decisions should be based on clinical judgment without the use of preoperative CT.
Available from: Emmanuelle Seguier
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ABSTRACT: To examine the role of CT scans and early surgical intervention in the management of pediatric patients with primary spontaneous pneumothorax (PSP).
Retrospective cohort study.
The authors identified 46 cases with 70 episodes of pneumothorax. The recurrence rate among conservatively treated patients was 50% both after the first and the subsequent episode. Recurrence rate in cases with and without blebs on CT was comparable. Initial episodes were treated with supplemental oxygen (n = 18) and chest tube drainage (n = 18), and 10 patients underwent video-assisted thoracoscopic surgery (VATS). The recurrence rate was significantly lower following surgical intervention compared with other therapy, and morbidity was comparable with that in patients who needed chest tube drainage.
Recurrence after the first episode of PSP in children is frequent and is difficult to predict by CT findings. VATS is safe and effective in preventing recurrences. Surgical intervention may be an attractive alternative in patients who require chest tube drainage for the first episode of PSP.
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