Quality of life evolution after surgery for primary or secondary spontaneous pneumothorax: a prospective study comparing different surgical techniques

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1 doi: /icvts Interactive CardioVascular and Thoracic Surgery 7 (2008) Institutional report - Thoracic general Quality of life evolution after surgery for primary or secondary spontaneous pneumothorax: a prospective study comparing different surgical techniques Abstract Bram Balduyck*, Jeroen Hendriks, Patrick Lauwers, Paul Van Schil Department of Thoracic and Vascular Surgery, University Hospital of Antwerp, Wilrijkstraat 10, B-2650 Edegem, Belgium 2008 Published by European Association for Cardio-Thoracic Surgery Received 22 May 2007; received in revised form 26 July 2007; accepted 30 July 2007 The objective of the present study is to evaluate quality of life (QoL) evolution after video-assisted thoracic surgery (VATS) and anterolateral thoracotomy (AT) for primary and secondary spontaneous pneumothorax, which has not been studied prospectively until now. From January 2003 to December 2004, QoL was prospectively recorded in 20 consecutive patients, using the European Organisation for Research and Treatment of Cancer (EORTC) QoL Questionnaire-C30 and the lung specific module LC-13. Questionnaires were administered before surgery and 1, 3, 6 and 12 months postoperatively (MPO) with response rates of 100%, 85%, 80%, 65% and 60%, respectively. In this prospective, non-randomized study, all patients had wedge resection and apical pleurectomy, 45% by video-assisted thoracic surgery (VATS), and 55% by anterolateral thoracotomy (AT). In general, patients QoL subscales improved after surgery. After VATS, pain (3 MPO Ps0.012), dyspnoea (1 MPO Ps0.030) and thoracic pain (1 MPO Ps0.038) decreased significantly. After AT, a significant increase was seen in general QoL (1 MPO Ps0.036, 3 MPO Ps0.034, 12 MPO Ps0.025), physical (6 MPO Ps0.025) and emotional functioning (12 MPO Ps0.017). Dyspnoea (12 MPO Ps0.042) and coughing (6 MPO Ps0.046) decreased after AT. After surgery, AT and VATS are comparable in QoL evolution with the exception of a significant difference at 1 MPO in physical, role and cognitive functioning (Ps0.002, Ps0.002 and Ps0.0018, respectively) and dyspnoea (Ps0.041) in favour of VATS. Comparing VATS and AT in QoL evolution, significant differences are seen in thoracic pain evolution in favour of VATS (6 MPO Ps0.037). After surgery, AT and VATS are comparable in QoL subscales with exception of a significant difference at 1 MPO in favour of VATS. Dyspnoea and coughing improved after surgery Published by European Association for Cardio-Thoracic Surgery. All rights reserved. Keywords: Quality of life; EORTC; QLQ-C30; QLQ LC-13; Spontaneous pneumothorax; Thoracotomy; Thoracoscopy; VATS 1. Introduction Recurrent spontaneous pneumothorax is a disabling disorder, which may present either in young and otherwise healthy patients (primary pneumothorax) or as a complication of an underlying lung disease (secondary pneumothorax) w1x. The current treatment options vary from observation, catheter aspiration, continuous thoracic drainage for first episodes of pneumothorax to chemical pleurodesis, videoassisted thoracic surgery (VATS) and thoracotomy for recurrent or persistent spontaneous pneumothorax w2x. Both VATS and thoractomy are effective methods for preventing recurrent pneumothorax with only 0.5% of the patients requiring repeat operation after thoracotomy and 5.3% after VATS treatment w2, 3x. Recent studies confirm the superior status of VATS in terms of decreased postoperative pain, preservation of postoperative pulmonary function, shorter hospital stay, and reduced morbidity compared to thoracotomy w4, 5x. Presented at the 15th European Conference on General Thoracic Surgery, Leuven, Belgium, June 3 6, *Corresponding author. Tel.: q ; fax: q address: bram.balduyck@uza.be (B. Balduyck). Recently, there has been increased recognition of the need to complement surgical treatment with an assessment of Quality of Life (QoL), in addition to the impact of treatment, survival and side effects. The purpose of the present study is to prospectively describe QoL evolution in patients undergoing surgery for primary or secondary spontaneous pneumothorax and to compare QoL evolution after VATS to thoracotomy. 2. Patients and methods From January 2003 to December 2004, 20 consecutive patients with a clinical diagnosis of primary or secondary pneumothorax were included. Dutch was their native language. All patients had wedge resection and apical pleurectomy, 45% by VATS, and 55% by anterolateral thoracotomy (AT). A recurrent spontaneous pneumothorax or an air leak persisting for )5 days constituted the inclusion criteria. Patients with empyema, malignant disease of the lung or pleura, or with conditions in which there was a potential need for future lung transplantation (e.g. cystic fibrosis) were excluded. Although a recent study w6x justifies the use of VATS for the first episode of

2 46 B. Balduyck et al. / Interactive CardioVascular and Thoracic Surgery 7 (2008) primary spontaneous pneumothorax, in our opinion these patients should initially be treated by chest tube drainage or aspiration w7x. In contrast, in patients with a secondary spontaneous pneumothorax related to chronic obstructive pulmonary disease, there is an associated increased mortality and a more aggressive approach is warranted consisting of initial thoracic drainage followed by recurrence prevention by VATS or AT w8x Surgical procedure Video-assisted thoracoscopic pleurectomy With the patient under general anaesthesia, ventilation was commenced with double-lumen intubation. The patient was prepared as for thoracotomy. Contralateral single-lung ventilation was begun before the initial 1.5-cm incision was made below the tip of the scapula in the sixth intercostal space. A 10-mm videothoracoscope was inserted via a 10.5 mm Thoracoport, the pleura already having been breached with a finger and the thoracic cavity inspected. If a single large bulla was identified, it was excised. Bullectomy was performed through two further 1.5-cm incisions anterior and posterior to the borders of the latissimus dorsi in the fourth intercostal space. The bulla was excised with the 30-mm stapling device. Apical parietal pleurectomy was then performed by blunt dissection to the level of the fifth rib using a curved artery forceps. Two intercostal drains were inserted through the anterior and lateral incisions and placed on continuous high-volume suction w4x Open pleurectomy by anterolateral thoracotomy With the patient under general anaesthesia using singlelung ventilation, an anterolateral thoracotomy was made through the fifth intercostal space. The ribs were spread only enough to allow a parietal pleurectomy to be performed from the level of the fifth rib, together with stapled excision of apical bullae, using stapling devices. The incision was closed in layers using absorbable material, including the pericostal sutures. Two drains were inserted through two separate incisions and placed on continuous highvolume suction w4x. After the operation, patients were extubated in the operating room and transferred to a critical care unit. Intercostal drains were removed when the underlying lung was fully expanded with no residual air leak. Patients were discharged from the hospital when fully mobile and when their pain was controlled by oral analgesia w4x QoL assessment QoL was prospectively recorded in all patients, using the Dutch version of the European Organisation for Research and Treatment of Cancer (EORTC) quality of life questionnaire (QLQ)-C30 (cancer core questionnaire) and the EORTC QLQ-LC13 lung cancer-specific questionnaire module. The EORTC QLQ-C30 (version 3.0) is a self-rating questionnaire composed of 30 questionsyitems and incorporates nine multi-item scales: five functional scales (physical, role, cognitive, emotional, and social), three symptom scales (fatigue, pain, nauseayvomiting), a global healthyqol scale, and several single items assessing additional symptoms (dyspnoea, sleep disturbance, constipation and diarrhoea). A final item evaluates the perceived economic consequences of the disease w9x. The EORTC QLQ-LC13 is a supplementary questionnaire module and contains 13 questionsyitems assessing lung cancer-associated symptoms (cough, haemoptysis, dyspnoea, and site-specific pain), chemotherapyyradiotherapy-related side effects, and pain medication w10x. Chemotherapyyradiotherapy-related side effects were not included in the analysis. Reliability and validity of the EORTC QLQ-C30 and LC-13 questionnaires have been confirmed in international cancer studies w9x. The questionnaires were administered one day before surgery and at 1, 3, 6 and 12 months postoperatively (MPO). The questionnaires were sent to the patients by mail, accompanied by a letter with general information and the aim of the study Statistical analysis Statistical analysis was performed using statistical software (SPSS, version 12.0, Chicago, IL). In accordance with procedures recommended by the EORTC, scores were linearly converted to a scale ranging from 0 and 100 for each patient. For the QoL and functional scales, higher scores represent a higher level of functioning. For the symptom scales, higher scores represent a greater symptom burden. Results are reported as means. The Wilcoxonsigned rank test was used to compare the mean values before and after surgery. Student s t-test was used to compare parametric QoL data between groups. The Mann Whitney U-test was performed to compare non-parametric QoL data between groups. A P-value of was considered as statistically significant. 3. Results 3.1. Response rate to QoL questionnaire and comparison of patient groups The preoperative baseline response rate to the QoL questionnaire was 100%, at one month 85.0%, at three months 80.0%, at six months 65.0% and at twelve months 60.0%. Response rate in the VATS group was at baseline 100%, at one month 81.8%, at three months 81.8%, at six months 45.5% and at twelve months 36.4%. In the AT group, the response rate at baseline was 100%, 88.9% at one month, 77.8% at three months and 88.9% at six and twelve months. Mean age at surgery was 37.7 years in the VATS group and 63.1 years in the AT group. Maleyfemale ratio was 9y1 in both groups. In the VATS group, 77.8% of patients had primary and 22.2% secondary spontaneous pneumothorax. In the AT group, all patients suffered from secondary spontaneous pneumothorax. No statistical differences were observed between VATS and AT regarding population characteristics and response rates with the exception of a significant difference in age (Ps0.009) and response rate at twelve months (Ps0.02) Preoperative QoL In general, patients complained of dyspnoea, coughing and thoracic pain. Patients reported a median impaired

3 B. Balduyck et al. / Interactive CardioVascular and Thoracic Surgery 7 (2008) global quality of life, physical and role functioning preoperatively at baseline, which was more pronounced in the thoracotomy group. Both access techniques were comparable in preoperative QoL subscale scores with the exception of emotional functioning (Ps0.032), cognitive functioning (Ps0.004), fatigue (Ps0.015) and coughing (Ps0.027) in favour of the VATS group. QoL at baseline and evolution is shown in Table QoL evolution after VATS After VATS, global QoL and QoL functioning scores approximated baseline preoperative values at one month after surgery. A significant decrease in dyspnoea after surgery was seen one month after VATS (Ps0.030). Thoracic pain and pain in general were significantly lower one month postoperatively (MPO) (Ps0.038) and three MPO (Ps0.012), respectively. Table 1 Mean baseline QoL functioning scores and mean changes from baseline as measured by the EORTC QLQ-C30 and LC-13. Enclosed are the P-values, indicating significance between the baseline value and the score after 1, 3, 6 and 12 months. No significance (NS) indicates return to baseline values Domain Mean baseline Mean score change from baseline (DT*) QoL scores 1 month 3 months 6 months 12 months QoL functioning scores* Physical functioning VATS (NS) 17.0 (NS) 13.4 (NS) 18.3 (NS) AT (NS) 14.4 (NS) 10.9 (Ps0.026) 20.8 (NS) Role functioning VATS (NS) 3.7 (NS) 23.4 (NS) 21.0 (NS) AT (NS) 33.3 (NS) 16.5 (NS) 29.0 (NS) Emotional functioning VATS (NS) 5.7 (NS) 10.0 (NS) 8.5 (NS) AT (NS) 22.7 (NS) 18.9 (NS) 26.3 (Ps0.016) Cognitive functioning VATS 96.9 y1.7 (NS) y1.8 (NS) 0.2 (NS) 8.3 (NS) AT 70.4 y8.4 (NS) y4.9 (NS) y8.3 (NS) 4.1 (NS) Social functioning VATS 71.3 y0.1 (NS) 12.9 (NS) 10.0 (NS) 21.0 (NS) AT (NS) 21.6 (NS) 2.1 (NS) 16.8 (NS) Global QoL VATS (NS) 16.8 (NS) 23.4 (NS) 20.5 (NS) AT (Ps0.036) 33.4 (Ps0.034) 14.6 (NS) 31.4 (Ps0.025) Symptom scores** 3.4. QoL evolution after anterolateral thoracotomy Taking into account the rather low baseline global QoL and QoL functioning scores of the thoracotomy group, a significant increase was seen in physical functioning (6 MPO Ps0.025), emotional functioning (12 MPO Ps0.017) and global QoL (1 MPO Ps0.036, 3 MPO Ps0.034 and 12 MPO Ps0.025) after AT. Patients reported a significant decrease in dyspnoea at twelve months (Ps0.042) and coughing at six months (Ps0.046). No differences in pain, thoracic pain and shoulder dysfunction were seen after AT Comparing QoL evolution after VATS and anterolateral thoracotomy After surgery, AT and VATS are comparable in QoL evolution with the exception of a significant difference one month after surgery in physical, role and cognitive func- Dyspnoea VATS 43.8 y22.2 (Ps0.029) y20.9 (NS) y46.7 (NS) y45.9 (NS) AT 53.8 y12.7 (NS) y23.9 (NS) y20.9 (NS) y23.0 (Ps0.041) Coughing VATS 12.0 y1.8 (NS) 2.1 (NS) y10.0 (NS) y8.3 (NS) AT 31.4 y8.3 (NS) y11.9 (NS) y16.7 (Ps0.046) y16.7 (NS) Pain in general VATS 34.8 y10.7 (NS) y17.3 (Ps0.012) y15.9 (NS) y12.6 (NS) AT 24.9 y0.5 (NS) y5.9 (NS) 10.9 (NS) y14.9 (NS) Thoracic pain VATS 48.5 y18.6 (Ps0.038) y20.9 (NS) y33.4 (NS) y16.8 (NS) AT (NS) 4.7 (NS) 20.9 (NS) y8.4 (NS) Shoulder dysfunction VATS 33.4 y11.2 (NS) y25.1 (NS) y26.8 (NS) y16.8 (NS) AT 22.2 y4.3 (NS) y9.4 (NS) 8.4 (NS) y12.5 (NS) *Mean changes from baseline: positive numbers indicate a higher functioning score at follow-up (i.e. improvement) compared to baseline, while negative numbers indicate a reduction in the mean score (i.e. deterioration). **Mean changes from baseline: positive numbers indicate more symptom burden at follow-up (i.e. deterioration), while negative numbers indicate a reduction in the symptom burden (i.e. improvement).

4 48 B. Balduyck et al. / Interactive CardioVascular and Thoracic Surgery 7 (2008) tioning (Ps0.002, Ps0.002 and Ps0.0018, respectively) and dyspnoea (Ps0.041) in favour of VATS. Comparing VATS and AT in QoL evolution, significant differences are seen in thoracic pain evolution in favour of VATS (6 MPO Ps0.037). 4. Discussion The outcome measurements of morbidity and mortality are insufficient when assessing the effect of thoracic surgery. QoL assessment by means of self-administered questionnaires has become a routine part of surgical research and is steadily gaining importance as an evaluation criterion for clinical decision-making w9x. Little is known about the QoL evolution in pneumothorax patients who have undergone surgery. The objective of the present study is to evaluate long-term quality of life evolution in patients undergoing VATS or thoracotomy, which has not been studied prospectively until now. The effect of VATS on quality of life compared to thoracotomy has extensively been studied in oncological resections. A recent study documents the early postoperative benefits of VATS such as less postoperative pain, less shoulder dysfunction, preservation of pulmonary function and earlier return to preoperative activity w10x. However, the long-term advantages of VATS over thoracotomy are yet to be determined. Li et al. compared QoL after lung cancer resection through VATS or posterolateral thoracotomy. Both groups enjoyed good QoL and high levels of functioning without significant differences between the groups w11x. In a recent retrospective questionnaire study set out to assess the prevalence of chronic pain after thoracic surgery, no differences were reported between VATS and thoracotomy w11x. These results are in accordance with the results obtained in the present study. Both access techniques are comparable in QoL evolution with the exception of a significant difference one month after surgery in dyspnoea, physical, role and cognitive functioning in favour of VATS. The immediate postoperative course after VATS compared to thoracotomy was studied by Waller et al. in a prospective randomized study w4x. The study showed a trend toward a lower postoperative analgesic requirement in patients treated by VATS. VATS patients were mobilized faster and had a shorter hospital stay. On the third postoperative day, the reductions in the forced expiratory volume in one second and forced vital capacity were significantly lower in the VATS group compared to thoracotomy. The benefits of VATS were less clear in patients with secondary spontaneous pneumothorax. A higher recurrence rate and a prolonged hospital stay are observed when VATS is used in this population. Waller et al. concluded that VATS is superior to thoracotomy for treatment of primary spontaneous pneumothorax, but is less reliable in patients with secondary spontaneous pneumothorax w4x. Bertrand et al. retrospectively compared VATS with thoracotomy in the treatment of primary spontaneous pneumothorax w13x. Both access techniques had equal frequencies in late postoperative thoracic pain. Passlick et al. studied a group of 60 patients who had a VATS procedure for spontaneous pneumothorax and found that after a median follow-up of 59 months, 32% still experienced chronic pain w14x. In the present study, patients undergoing VATS had a favourable pain evolution compared to thoracotomy. After VATS, patients complained of significantly less pain in general and at the thoracic level. Körner et al. evaluated the subjective effect of the treatment of pneumothorax by thoracotomy by questionnaire w15x. The authors reported subjective complaints in 37% of patients, which were related to the pneumothorax intervention. The most common symptoms were diffuse chest pain, breathlessness and hypo- or hyperaesthesia in the scar region w15x. In the present study, a significant decrease in dyspnoea after surgery was seen one month after VATS. After thoracotomy, patients reported a significant decrease in coughing at six months and dyspnoea at twelve months. The present study has several limitations. A valid and reliable measurement of QoL is of utmost importance. In the present study, QoL was assessed by the QLQ-C30 and LC-13. The reliability and validity of the EORTC questionnaires have been confirmed in stage III and IV lung cancer patients only w9x. It is unknown whether these standardized questionnaires are also applicable to patients with benign thoracic disease. The results of the present study need to be interpreted with caution because of the rather limited number of patients included in the study. In addition, the patients were not randomized between the two treatment groups, thoracotomy being reserved for patients with secondary spontaneous pneumothorax and severe underlying lung disease. This prospective study represents a first step in documenting intermediate to long-term QoL evolution in patients undergoing thoracic surgery for pneumothorax. As both access techniques are not comparable, the results are not intended to influence the choice of access in pneumothorax cases, which depents mostly on the specific presentation. Despite the mentioned limitations, the findings of the study offer valuable information in understanding the evolution in QoL after surgery for pneumothorax and in that way may create realistic postoperative objectives for patients. In conclusion, quality of life evolution was prospectively recorded comparing preoperative status with deficits and changes at 1, 3, 6 and 12 months after VATS and anterolateral thoracotomy for primary and secondary pneumothorax. Pneumothorax surgery is well tolerated by the majority of patients. In general, patients QoL subscales improved after surgery. After VATS, pain, dyspnoea and thoracic pain decreased significantly. After anterolateral thoracotomy, a significant increase was observed in general QoL, physical and emotional functioning. Dyspnoea and coughing decreased after anterolateral thoracotomy. Both techniques were comparable in QoL evolution. However, one month after surgery, physical, role, cognitive functioning and dyspnoea were significantly better in the VATS group. VATS also had a favourable thoracic pain evolution compared to anterolateral thoracotomy. Acknowledgements The authors are grateful to Gina Clerx, Sarah Balduyck and Annelies Masschelin for their help in the data management.

5 B. Balduyck et al. / Interactive CardioVascular and Thoracic Surgery 7 (2008) References w1x Massard G, Thomas P, Wihlm JM. Minimally invasive management for first and recurrent pneumothorax. Ann Thorac Surg 1998;66: w2x De Vos B, Hendriks J, Van Schil P, Van Hee R, Hendrickx L. Long-term results after video-assisted thoracic surgery for spontaneous pneumothorax. Acta Chirg Belg 2002;102: w3x Weeden D, Smith GH. Surgical experience in the management of spontaneous pneumothorax. Thorax 1983;83: w4x Waller DA, Forty J, Morrit GN. Video-assisted thoracoscopic surgery versus thoracotomy for spontaneous pneumothorax. Ann Thorac Surg 1994;58: w5x Giudicelli R, Thomas P, Lonjon T. Video-assisted minithoracotomy versus muscle-sparing thoracotomy for performing lobectomy. Ann Thorac Surg 1994;58: w6x Torresini G, Vaccarili M, Divisi D, Crisci R. Is video-assisted thoracic surgery justified at a first spontaneous pneumothorax? Eur J Cardiothorac Surg 2001;20: w7x Van Schil P. Spontaneous pneumothorax: needle aspiration or chest drain? Evidence based medicine. Acta Chir Belg 2002;102: w8x Van Schil P, Hendriks J, De Maerseneer M, Lauwers P. Current management of spontaneous pneumothorax. Monaldi Arch Chest Dis 2005; 63: w9x Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ. The European Organisation for Research and Treatment of Cancer QLQ- C30: a quality of life instrument for use in international clinical trials in oncology. J Natl Cancer Inst 1993;85: w10x Swanson SJ, Batirel HF. Video-assisted thoracic surgery (VATS) resection for lung cancer. Surg Clin North Am 2002;82: w11x Li WW, Lee TW, Lam SS, Ng CS, Sihoe AD, Wan AY. Quality of life following lung cancer resection: video-assisted thoracic surgery vs. thoracotomy. Chest 2002;122: w12x Maguire MF, Ravenscroft A, Beggs D, Duffy JP. A questionnaire study investigating the prevalence of the neuropathic component of chronic pain after thoracic surgery. Eur J Cardiothorac Surg 2006;29: w13x Bertrand PC, Regnard JF, Spaggiari L, Levi JF, Magdeleinat P, Guibert L, Levasseur P. Immediate and long-term results after surgical treatment of primary spontaneous pneumothorax by VATS. Ann Thorac Surg 1996; 61: w14x Passlick B, Born C, Sienel W, Thetter O. Incidence of chronic pain after minimal-invasive surgery for spontaneous pneumothorax. Eur J Cardiothorac Surg 2000;17: w15x Körner H, Andersen HS, Stangeland L, Ellingsen I, England H. Surgical treatment of spontaneous pneumothorax by wedge resection without pleurodesis or pleurectomy. Eur J Cardiothorac Surg 1996;10: Conference discussion Dr. K. Athanassiadi (Athens, Greece): What is the clinically implication of your study? Dr. B. Balduyck: I m well aware that both access techniques aren t comparable. The purpose of the present study is however to compare the evolution between both techniques. As one would expect, the more extensive and radical thoracotomy would have a higher effect on QoL subscale score evolution than the more minimal invasive thoracoscopy. However this differences in quality of life evolution expected between the two techiques after surgery aren t that pronounced. This prospective study represents a first step in documenting intermediate to longterm QoL evolution in patients undergoing thoracic surgery for pneumothorax. The results of this study are not intended to influence the choice of access in pneumothorax cases, which depends mostly on the specific presentation. The findings of the present prospective study offer valuable information in understanding the evolution in QoL after thoracocotym and thoracoscopy and in that way may create realistic postoperative objectives for pneumothorax patients. Dr. T. Szczesny (Warsaw, Poland): For videothoroacoscopic pleurectomy we always try to use a single incision access, with the use of optics designed for biopsy. This picture is darker but this technique is feasible and allows avoid an additional incision made for preoperative drainage can be used. The present study isn t randomised. How did you choose between both access techniques. Dr. B. Balduyck: This prospective study is not randomized. A blinded study protocol to evaluate quality of life between VATS and thoracotomy is, as many research projects in surgery, ethically not feasible. The choice between VATS and the anterolateral technique wasn t influenced by this study. All patients underwent VATS unless technically impossible or too extensive disease, as most cases of SSP were.