Video-assisted thoracoscopic surgery (VATS) represents

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1 Long-Term Results After Video-Assisted Thoracoscopic Surgery for First-Time and Recurrent Spontaneous Pneumothorax Rudolf A. Hatz, MD, Michaela F. Kaps, MD, Georgios Meimarakis, MD, Florian Loehe, MD, Christian Müller, MD, and Heinrich Fürst, MD Department of Surgery and General Thoracic Surgery, Klinikum Grosshadern, Ludwig-Maximilians-University of Munich, Munich, Germany Background. Few investigators have reported on results after video-assisted thoracoscopic surgery (VATS) for spontaneous pneumothorax (SP) with follow-up periods longer than 24 months. The aim of this study was to evaluate VATS for first-time and recurrent SP and to follow patients long-term. Methods. One hundred nine patients were followed long-term after treatment of SP by VATS. Ninety-five patients had primary SP and 14 had secondary SP. Sixty-two patients had a first episode and 47 had a recurrence. In 72 patients leaks or ruptured blebs were identified and excised without subsequent pleurodesis. In 37 patients showing no ruptured bullae or leaks only pleurodesis was applied. Results. Median follow-up was 53.2 months. Postoperative complications were rare. Three patients (2.7%) had a prolonged air leak. The long-term recurrence rate was 4.6%. Only those patients who had not received pleurodesis at the time of first treatment by VATS experienced recurrence. Conclusions. Immediate postoperative results show VATS to be a safe and reliable method in first-time and recurrent SP to obtain quick reexpansion of the lung. Long-term recurrence rates are acceptable and compare with results after open thoracotomy. Pleurodesis should be included in each procedure for adequate recurrence prevention. (Ann Thorac Surg 2000;70:253 7) 2000 by The Society of Thoracic Surgeons Video-assisted thoracoscopic surgery (VATS) represents a new approach for operative treatment of spontaneous pneumothorax (SP). Although the first thoracoscopy was performed by Jacobeus in 1910 [1], this technique was employed primarily for diagnostic purposes, and therapeutic procedures in SP were limited [2]. The introduction of video technology offers excellent visualization of the pleura and lung. This advantage combined with minimally invasive techniques and newly developed endoscopic equipment permits intraoperative interventions to be performed safely, making it possible not only to treat SP episodes successfully but more importantly to provide adequate recurrence prevention. Since its first introduction in 1990 and the first report by Levi and colleagues [3] on its use in surgical treatment of SP, several studies have reported on its efficacy, low morbidity, cost-effectiveness, and immediate or shortterm treatment results [4 6]. Considered a safe and reliable method when performed by surgeons with sufficient training in VATS procedures, it is now increasingly under discussion whether the indication for operative treatment of SP should include first-time episodes Accepted for publication Jan 12, Address reprint requests to Dr Hatz, Department of Surgery and General Thoracic Surgery, Klinikum Grosshadern, Ludwig-Maximilians- University, Marchioninistr 15, Munich, Germany; hatz@gch.med.uni-muenchen.de. [7]. To date, it had been generally recommended that these should only be included if prolonged air leakage after chest tube drainage was observed for periods longer than 48 hours and if a recurrence was thought to be unacceptable, eg, in airline pilots or divers or in persons living in areas not within the reach of adequate medical attention [8]. Long-term follow-up data are very important for the evaluation of recurrence control when using this new minimally invasive technique in treatment of SP. However, only a few investigators have reported on results with follow-up periods longer than 24 months [9, 10]. These studies did not include the treatment of first-time episodes without prolonged air leakage. Conservative treatment regimens, eg, simple aspiration or pleural drainage with chest tubes, show unacceptable recurrence rates of 40% and more [11]. Not only are the recurrence rates very high, but treatment of recurrence in the long run leads to a net increase in costs, not to mention the morbidity and discomfort the patient must suffer during recurrence. Thoracotomy with bullectomy and pleurectomy is considered the established gold standard in preventing recurrence with long-term recurrence rates reported from 0% to 5% [12]. However, this approach may lead to significant postoperative morbidity due to thoracotomy. Thus, VATS may represent a compromise between low postoperative morbidity and the possibility of adequate recurrence control by The Society of Thoracic Surgeons /00/$20.00 Published by Elsevier Science Inc PII S (00)

2 254 HATZ ET AL Ann Thorac Surg VATS FOR SPONTANEOUS PNEUMOTHORAX 2000;70:253 7 Table 1. Patients Followed After VATS Treatment for Spontaneous Pneumothorax Incidence Primary Spontaneous Pneumothorax Secondary Spontaneous Pneumothorax Total No. Mean Age (y) Sex (F:M) No. Mean Age (y) Sex (F:M) No. Mean Age (y) Sex (F:M) First episode : : :41 Recurrence : : :33 Total : : :74 F female; M male; VATS video-assisted thoracoscopic surgery. It was therefore the aim of this study to follow patients long-term and to evaluate whether VATS for first-time and recurrent SP may be an acceptable treatment alternative in preventing recurrence. Material and Methods Patient Characteristics Between June 1991 and June 1997, 118 consecutive patients were treated for SP by VATS. Nine patients were lost to follow-up; thus 109 patients could be followed long-term. In the group that was followed, 95 patients had suffered primary SP (PSP) and 14 patients secondary SP (SSP). Fifty-three patients in the PSP group experienced a pneumothorax for the first time and 42 had a recurrence (Table 1). In the SSP group 9 patients had a first episode and 5 had a recurrence. The underlying lung diseases in SSP were chronic obstructive lung disease with emphysema in 5 patients, mucoviscidosis in 4, idiopathic fibrosis in 3, tuberculosis in 1, and lymphangioleiomyomatosis in 1. Technique After roentgenographic confirmation of pneumothorax all patients underwent operation within 24 hours of admission. No invasive procedures were performed preoperatively if the size of the pneumothorax did not exceed 20% of the volume of the hemithorax and did not progress. If large pneumothorax volumes led to excessive dyspnea and patient discomfort at admission preoperative pleural drainage was performed by inserting a 20F plastic chest tube into the fifth intercostal space in the midaxillary line. In each case, however, VATS was undertaken. VATS was performed in the operating room by a thoracic surgeon during general anesthesia using a double-lumen endotracheal tube that allowed ventilation of the contralateral lung while the ipsilateral lung remained in atelectasis. Patients were positioned in the lateral decubitus position and prepared and draped to allow open thoracotomy should conversion become necessary. If a chest tube was in place before operation it was removed before preparation and draping and its entry used for placement of the first port, which was a 15 mm port in the fifth intercostal space in the midaxillary line. After introduction of a 10 mm rigid thoracoscope with a 30-degree lens (Olympus Corp, Hamburg, Germany), a second 10 mm port was placed in the fourth intercostal space in the anterior axillary line under direct thoracoscopic visualization. In the majority of cases only two ports of entry were necessary. Insufflation of carbon dioxide was not used. If blebs or bullae were present they were grasped with an endoscopic forceps through the 10 or 15 mm port, and excision was performed using an endoscopic stapling device (Endo-Cutter 35 mm, Ethicon Corp, Norderstedt, Germany) which was introduced through the 20 mm port. An air leak was identified by instilling Ringer s solution into the pleural cavity and ventilating the collapsed lung. If no blebs or bullae and no air leak were found only apical pleurodesis was performed. These were electrocoagulated using scissors or hook, partial or total pleurectomy, or talc powder. Partial pleurectomy was established from the fifth intercostal space both anteriorly and posteriorly. For talc pleurodesis 4 g of dry asbestos-free talcum was sprayed onto the apical surface of the lung and parietal pleura. At the end of the procedure one 20F plastic chest tube was placed through the 15 mm incision toward the apex of the pleural cavity and connected to an underwater seal suction with a negative pressure of 20 cm H 2 O. Expansion of the lung was reconfirmed by x-ray film immediately after termination of the procedure and the chest tube removed after 24 to 48 hours if air leakage had ceased. Data Collection and Statistics The medical records of all patients with first-time or recurrent SP admitted to the department between 1991 and 1997 were reviewed retrospectively. Follow-up was obtained by letter, telephone, or clinical examination in our outpatient department. Freedom from recurrence was analyzed by the Kaplan-Meier method. Results The median follow-up was 53.2 months (range, 2.0 to 86 months). This study was 92.4% complete. Nine patients could not be reached during follow-up. Of our patient population, 56.9% had a first episode of pneumothorax and 43.1% had their first or second recurrence. In 72 patients with first-time or recurrent episodes of both PSP or SSP in which ruptured blebs, bullae, or air leaks within normal lung tissue were identified, excision using an endostapling device was performed without subsequent pleurodesis. In the other 37 patients in whom no imminent ruptured blebs, bullae, or leaks were encountered

3 Ann Thorac Surg HATZ ET AL 2000;70:253 7 VATS FOR SPONTANEOUS PNEUMOTHORAX 255 Fig 1. Kaplan-Meier curve of freedom from recurrent spontaneous pneumothorax after VATS treatment. only larger intact bullae were removed by stapling and in addition pleurodesis was applied. Postoperative Period There was no need for conversion to open thoracotomy in any of the patients. Mean operating time was minutes (mean SEM). No patient required monitoring in the intensive care unit. No postoperative complications were seen, eg, bleeding, pneumonia, incomplete reexpansion, empyema, or pronounced skin or mediastinal emphysema. Three patients had a prolonged air leak ( 48 hours) and underwent reoperation. In 1 patient with recurrent PSP a missed ruptured bulla was removed by open thoracotomy. One patient who had undergone VATS with endostapling and excision of a large bulla had leakage at the staple line. Closure was performed using VATS and restapling using an Endo-Cutter. The third patient with emphysema and a first episode of SSP had had bulla resection by VATS with prolonged leakage caused by an incomplete staple margin. This patient also underwent reoperation by VATS and the staple line was closed by using bovine pericardial strips to reinforce the staple line in the emphysematous lung tissue. The postoperative course was uneventful for all 3 patients. The median postoperative stay was 4 days (range, 2 to 14 days) in the PSP patient group and 8 days (range, 1 to 18 days) in the SSP group. Long-Term Follow-up The overall long-term recurrence rate was 4.6%, a total of 5 patients (Fig 1). Three patients suffered a recurrence within 6 months after hospital discharge: at 2, 3.5, and 5 months. Two patients had recurrent SP after a longer time period: 25 and 37 months. Initially, 4 of these patients had been treated at our department for first-time PSP and 1 patient for first-time SSP. Relapse SP in 2 of these 5 patients was treated by chest tube drainage alone. This was performed at a different hospital. Three patients who had recurrent SP during follow-up and were referred to our center underwent reoperation using VATS. During all three procedures bulla resection and pleurodesis were performed. Postoperative periods were uneventful. Interestingly, only those patients who had not received pleurodesis at the time of first treatment by VATS experienced recurrence. Comment Although simple aspiration and chest tube drainage are still the most frequently applied methods for treatment of SP, especially the first episode, these procedures have major disadvantages. Prospective trials have shown that reexpansion of the collapsed lung is only achieved in approximately 60% to 70% after aspiration and 75% to 95% after chest tube drainage [13], and these treatment options do not prevent recurrence. A study by Schoenenberger and coworkers [8] showed 18% of patients with PSP and 40% with SSP treated by chest tube drainage had persistent air leakage for a period longer than 48 hours requiring operative treatment, and 34% of those patients initially treated successfully by chest tube placement alone suffered a recurrence during a mean follow-up of 7 months. Taken together in a long-term perspective more than 50% of patients required operative treatment after chest tube drainage. Therefore, the two major objectives in treating SP must be reliable and immediate lung reexpansion and long-term recurrence prevention. Attainment of these goals will not only reduce morbidity and patient discomfort but also in the long run have a net effect on costs. In the present study, treatment of PSP and SSP by VATS was evaluated along with the employment of this method as a more aggressive approach in the treatment of first-time SP. Immediate results show that the procedure is a safe and reliable method with short operating times in obtain-

4 256 HATZ ET AL Ann Thorac Surg VATS FOR SPONTANEOUS PNEUMOTHORAX 2000;70:253 7 ing quick reexpansion of the collapsed lung. No serious postoperative morbity was observed. Persistent air leakage during the postoperative period was encountered in 2.7% of our patients. This most frequent postoperative complication was certainly due in part to the limited experience with this new technique after its introduction to our center in The first two leaks occurred in patients undergoing operation in February and June of 1992, the third in August of In the first patient with prolonged air leakage a bulla was missed. In the beginning of VATS we used a thoracoscope with a 0-degree lens which, as we now know in retrospect, does not permit complete exploration of the pleural cavity unless the thoracoscope is inserted through different ports to allow for viewing at different angles. Therefore, we changed to a thoracoscope with a 30-degree lens after this experience. In the second patient with leakage at the staple margin the stapling line at the base of a bulla had not been placed far enough within a sufficient margin of healthy lung tissue. The third postoperative leakage occurred in a patient with severe lung emphysema. Staple lines had initially not been buttressed using pericardial strips. We now routinely use them in patients with SSP presenting with diseased lung tissue. The postoperative morbidity rate of the present series is lower than the average morbidity rates between 5% and 10% reported by others [6, 7, 9, 14]. However, all studies found the persistent postoperative air leak to be the principal postoperative complication after VATS. We report a median follow-up period of 53.2 months (range, 2 to 86 months) in this study. Others have reported follow-up results of up to 30 months [6, 9, 10]. In the present series three of five recurrences appeared within 6 months after VATS treatment. However, two were observed after medium-term to long-term time periods of 25 and 37 months postoperation. This means that they would have been missed if only short-term follow-up results were obtained as in most studies reported in the literature. Interestingly, all 5 patients who had SP relapse during follow-up had not had pleurodesis performed during the initial VATS procedure. This demonstrates the major importance of pleurodesis and confirms the results of other studies employing open thoracotomy or VATS for treatment of SP [15, 16]. These reported significantly higher recurrence rates if pleurodesis of some form had been omitted. With adequate recurrence prevention in mind we initially thought it to be sufficient to control for leakage by thoracoscopic resection of ruptured blebs or bullae, especially in patients presenting with first-time PSP or SSP, as we believed that additional pleurodesis of some form would substantially increase morbidity, as others had observed [16]. Furthermore, we thought it favorable to leave the pleura untouched and preserve the extrapleural space so that future thoracotomy for other reasons would not be complicated by pleural adhesions and granuloma formation. Our data and those of other groups favor immediate VATS for the generally accepted indications of operative intervention in recurrent SP. Postoperative morbidity rates including our own are far lower after VATS compared with open thoracotomy with wedge resection and pleurodesis, after which most series report morbidity rates between 14% and 18% [12]. Also, the long-term recurrence rate of 4.6% that we report in this study substantiates the short-term to medium-term rates between 0% and 6% which most investigators have observed [6, 7, 9, 17, 18]. As to extending the indication for immediate VATS intervention to patients presenting with their first episode of SP we believe that this more aggressive approach may be feasible in centers with surgeons adequately trained in VATS procedures [19]. Almost 50% of patients with first-time SP at some point require operation either because of persistent leakage or because of later recurrence [8]. The method is safe with a low long-term recurrence rate, and it is the only technique that may control for persisting emphysematous changes in the lung which may lead to recurrence. We identified pulmonary blebs or bullae in the majority of patients with first-time PSP (76.8%) and recurrent PSP (70%) during VATS. This observation complies with the data of several other reports in which a high incidence (up to 80%) of blebs or bullae was seen in patients undergoing VATS for first-time or recurrent SP episodes [7, 9, 10]. These findings find further support in recent studies evaluating high-resolution computed tomography in SP which have reported emphysema-like changes in 80% of patients who had first-time PSP as opposed to patients who had never experienced SP [20, 21]. Further modifications in VATS such as performing the procedure in local anesthesia as reported by others [22] together with further evaluation of this technique in controlled studies could make it a generally accepted method of choice even in first-time SP. This study was supported by a research grant from the Chiles Foundation (Portland, OR). We thank Mrs Heide Leicht for assistance in preparing the manuscript. References 1. Jacobeus HC. Über die Möglichkeit die Zystoskopie bei Untersuchung seröser Höhlen anzuwenden. Muench Med Wochenschr 1910;40: Kaiser D, Wolfart W. Therapeutic principles in the treatment of spontaneous pneumothorax with special reference to thoracoscopic ablation of emphysematous bullae and fibrin application. 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