minimally invasive techniques

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1 minimally invasive techniques Thoracoscopic Wedge Resection of Blebs Under Local Anesthesia With Sedation for Treatment of a Spontaneous Pneumothorax* Kunimoto Nezu, MD; Keiji Kushibe, MD; Takashi Tojo, MD; Makoto Takahama, MD; and Soichiro Kitamura, MD, FCCP We performed thoracoscopic wedge resections of blebs with a stapling device under local anesthesia with sedation in 34 consecutive patients who presented with spontaneous pneumothoraces. The indications for surgery included the absence of parietal pleural adhesions and knowledge of the precise bleb location prior to the procedure. Prior to surgery, 0.5% lidocaine was administered into the pleural space, and IV butorphanol tartrate and diazepam were administered to reduce pain and anxiety during the procedure. In our series, the thoracoscopic procedure resulted in favorable outcomes in all but two patients. There was no evidence of hemodynamic instability or arterial blood gas abnormalities encountered during the procedure. Minor postoperative complications were seen in only th1 ee patients (two with air leakage and one with transient atelectasis). One patient had a recurrence of his spontaneous pneumothorax 3 months following the procedure. Therefore, the overall success rate was 91%. We compared the results of this therapeutic modality (group I) with those of 38 patients who underwent the procedure under general anesthesia (group 2) dming the same peliod. The length of hospital stay was shorter in group 1 than in group 2 (4.5±1.3 vs 5.8±1.1 days; p<o.ol). Thoracoscopic wedge resections under local anesthesia are safe and offer the benefit of shorter hospital stays. We believe that this thoracoscopic technique will further simplify the surgical treatment of pneumothoraces without incrementallisks. (CHEST 1997; 111:230-35) Key words: local anesthesia; spontaneous pneumothorax; thoracoscopic wedge resection Abbreviations: HR=heart rate; Sa0 2 = arterial oxygen saturation; VATS =video-assisted thoracoscopic surge1y R ecently, increased use of thoracoscopy has led to the widespread application of this technique for the treatment of many thoracic disorders. Spontaneous pneumothorax may be ideally suited for thoracoscopic management. L-.5 Endoscopic stapling equipment has been used for pulmonary wedge resections and has become employed more and more during thoracoscopy. 6-8 Thoracoscopy usually is performed under general anesthesia vvith the use of doublelumen endobronchial intubation. *From the Department of Surgery Ill, Nara Medical College, :\ ara, Japan. Manuscript received }anua1y 18, 1996; revision accepted July 11. Reprint requests: Kuninwto Ne;:,u, Dept of Thoracic and Cardiovascular Surgery, Nara Medical College, 840 Shijo-Cho, Kashihara, Nara 634 Japan 230 Since 1992, we have treated spontaneous pneumothoraces thoracoscopically using endostapling devices. We used local anesthesia with IV sedation dming thoracoscopic wedge resections for selected spontaneous pneumothoraces to further simplify the thoracoscopic treatment of the disease. The present report describes our e:>.:pe1ience with this thoracoscopic wedge resection under local anesthesia in 34 consecutive patients vvith pneumothoraces, and compares these patients with 38 comparative individuals treated under general anesthesia during the same period. MATERIALS AND METHODS All patients were treated witb tube thoracostomy drainage prior to surgery. Nine patients (26%) developed pneumolborax the first Minimally Invasive Techniques

2 time, but tube drainage for more than 7 days had failed. The remaining 25 patients (74%) had 2 to 6 episodes of pneumothorax. The indications for a thoracoscopic wedge resection for the treatment of spontaneous pneumothorax under local anesthesia with sedation were the absence of parietal pleural adhesions and the precise preoperative localization of blebs. Between March 1992 and April 1995, 72 patients with a spontaneous pneumotl1orax underwent thoracoscopic surgery. Thirty-four of the 72 patients (47%) were treated under this protocol (Table 1). The other 38 patients were treated conventionally under general anestl1esia with a doublelumen endotracheal tube for comparison. All patients gave informed consent prior to surgery. Prior to surgery, we localized each bleb by chest radiograph and CT. To diagnose parietal pleural adhesions, 500 ml room air was injected into the thoracic cavity through the chest tube (Fig 1). If the lung became freely detached from the outer thoracic wall, this confirmed the absence of pleural adhesions. Operatit;e Technique All thoracoscopic procedures were performed in the operating room. The patients were premedicated with 50 mg of meperidine and 0.5 mg of atropine sulfate, both given IM. Thirty minutes prior to surgery, 0.5% lidocaine was administered into the pleural space, and 1 mg of butorphanol tartrate and 5 mg of diazepam were both given IV to reduce pain and anxiety. The patients were placed in the decubitus position and given 2 Umin of oxygen by nasal cannula. The intercostal nerve above and below the selected interspace was anesthetized with local anesthesia. Then, room air (500 ml) was injected into the thoracic cavity through a chest tube to confirm the presence or absence of pleural adhesions. A 5-mm port was placed in the fifth or sixth intercostal space in the midaxillary line. This pmi contains a flapper valve with an insufflation stopcock. The thoracic cavity then can be maintained as a closed system. The degree of the lung collapse with pleural insufflation can be controlled by immediately applying suction to or by injecting room air through ilie stopcock (Fig 2). A5-mm rigid thoracoscope (Model No ; Cabot Medical Corp, Langhorne, Pa) was used to visualize the thoracic cavity. The rigid scope was introduced into the thorax through the 5-mm port. The entire thoracic cavity was inspected carefully paying particular attention to the apex of the upper lobes and the superior segment of the lower lobes. A second 5-mm port was placed through the fourth or fifth intercostal space in the auscultatory triangle to introduce grasping forceps. This enabled the surgeon to manipulate the lung and aid in further thoracic exploration. After the bullous disease had been identified, a 12-mm port was placed through the third or fourth intercostal Table!-Clinical Data of Patients Undergoing the Procedure Under Local Anesthesia* Location No. of Operation No./Sex/Age, yr of Blebs Blebs Time, min Complication Result l!mi30 LLL 1 65 None Success 2!MI48 RUL 3 60 Air leakage Success 31MI20 RUL 57 None Success 4/MI21 LUL 1 55 None Success 51FI17 RUL 1 53 None Success 61MI22 RUL 2 48 None Success 71MI19 LUL 1 52 None Success 81MI18 RUL 4 63 Atelectasis Success 91MI20 LUL 2 30 None Success 101FI22 LUL 2 48 None Success 111MI22 LUL 2 52 None Success 121MI17 RUL 1 45 None Success 131MI18 RUL 2 25 Air leakage Success 14/Mil9 RUL 1 46 None Success 151MI 19 RUL 35 None Success 161MI20 RUL 1 48 None Success 171MI18 RUL 2 40 None Recurrent 181MI42 LUL 50 None Success 191MI16 RU U RLL 2 60 None Success 201MI18 LUL 1 48 None Success 211MI18 LUL 36 None Success 22/M/78 LUULLL Failure 231MI61 RUL 32 None Success 24/MI18 LUL Failure 251MI29 RUL 2 46 None Success 261F117 LUULLL 2 55 None Success 271MI21 RUL 1 25 None Success 281MI18 LUL 3 58 None Success 291MI18 LUL 2 36 None Success 301MI17 LUL 1 28 None Success 311MI18 RUL 3 43 None Success 321MI24 RUL 26 None Success 331MI36 LUL 2 34 None Success 34/MI19 RUL 1 31 None Success *M= male; F=female; RUL = right upper lobe; RLL= right lower lobe; LUL=Ieft upper lobe; LLL=left lower lobe. CHEST I 111 I 1 I JANUARY,

3 Thoracoscope FIGURE 1. The method for diagnosing the presence or absence of pleural adhesions; 500 ml of room air was injected into the pleural space. No pleural adhesions were confirmed on subsequent chest radiographs. FIGURE 2. The procedure of tl1oracoscopic wedge resection under local anesthesia with s edation. The patient was placed in the lateral decubitus position. A port containing a flapper valve and insufflation stopcock was used in conjunction with room air insufflation through a chest tube to collapse the lung. A 5-mm thoracoscope was inserted through the pmt in the fifth intercostal space a t the midaxillary line. A stapler (Endo-GIA) was placed in the third intercostal space port in the anterior axilla1y line. space in the ipsilateral anterior axillary line for the inb oduction of tl1e Endo-GIA30 (Centmy Medical Corporation; Japan ). Thoracoscopic wedge resection of the pulmomuy parenchyma at the base of the bleb was accomplished in all patients. Following resection of all visible blebs, we pe1fonned Bb1in glue pleurodesis according to Hansen et al 2 to decrease tl1e postoperative air leak ;md tl1e 1isk of recujtence by placing fibjin glue on the visceral pleura. Tube drainage of the pleural space was routinely carried out by inserting a 24F thoracostomy tube tl1rough one of the pmt sites. Following the operation, patients were encouraged to use incentive spirometry with breathing exercises to reexpand tl1e lung. A chest radiograph was obtained postoperatively to con finn full expansion of tl1e lung. All patients were monitored dming tl1e operation for changes in cardiac rhytl1m, BP, and arterial oxygen saturation (Sa0 2 ). All patients had an arterial catl1eter placed to measure Pa0 2 and PaC0 2 during tl1e procedure. Changes in hemodynamics and arterial blood gas during the procedure were s tatistically evaluated u sing the analysis of v a ~ i a n followed b y the Tukey's multiple comparisons test. Compa.Iisons between patients treated under local ;mesthesia and general anestllesia were statistically analyzed using a Student's unpaired t test. The x 2 test was used to compare the values that were expressed as percentages b etween the two groups. A difference was considered statistically signifla mt when p value was less than RESULTS Thoracoscopic wedge resections for spontaneous pneumothoraces performed under local anesthesia 232 c e with sedation were successful in all but two patients. One of these patients was a 78-year-old man (case 22) who developed dyspnea during the procedure as a result of anxiety, but had no hemodynamic instability. The other patient was an 18-year-old man who had had severe empyema resulting in severe pleural adhesions (case 24). These two patients successfully underwent an open thoracotomy for resection of blebs several days after the initial trial. In 32 successful cases, there was no significant morbidity with this procedure. Local anesthesia with sedation was judged to be adequate in all cases. Aside from minor local discomfort at the portal sites, the only other intraoperative symptom was an irritating cough when the parietal pleura was touched in three patients. The changes in hemodynamics and arterial blood gas values during the procedure are shown in Table 2. The heart rate (HR) increased hom 91±13 beats/ min before the procedure to 108±11 beats/min during the procedure or 110±10 beats/min after the procedure. The Sa0 2 under inhalation of 2 Umin of oxygen dropped from 100 to 98±2% during or after the procedure. Pa0 2 dropped from 150±35 to 106±16 mm Hg during the procedure or 102±12 Minimally Invasive Techniques

4 Table 2-Changes in Hemodynamics and Arterial Blood Gas Analysis of Systolic BP, HR, Sa0 2, Pa0 2, and PaC0 2 Prior to, During, and Following the Procedure* Before During After Systolic BP, mm Hg 118:!::10 124:!:: :!::12 HR, beats/min 91:!::13 108:!::11 110:!::10 1 I ' ' Sa0 2,% :!::2 98:!::2 Pa0 2, mm Hg 150:!:: :!:: 16 ' 102:!::d PaC0 2, mm Hg 41:!::3 46:!::4 1 45:!::4 1 *Results are the means:!::sds. Data were collected under inhalation 1 of 2 Umin of oxygen. Significantly different from the values before the procedure (p < O.Ol). 1 Significantly diffe rent from the values before the procedure (p < 0.05). mm Hg after the procedure, all within the safety limits. PaC0 2 increased from 41±3 to 46±4 during the procedure and 45±4 after the procedure, all within the tolerance limits. Lung deflation was well tolerated, presumably because the lung did not completely collapse under local anesthesia. Apercutaneous oximeter available for use in all patients showed only minor desaturation during the procedure. There was a mean fall of Sa0 2 by 2.0%, and the lowest Sa0 2 recorded during the procedure was 92%. The lowest Pa0 2 recorded was 90 mm Hg, and the highest PaC0 2 was 50 mm Hg under inhalation of 2 Umin of oxygen. There was no hemodynamic instability encountered in any of the patients. The only cardiac dysrhythmia that occurred during the procedure was sinus tachycardia, with a maximum HR of 120 beats/min. In the 32 successful cases, the patients had had no pleural adhesions. Pulmonary bullous disease could be identified immediately following insertion of a thoracoscope. An average of 1.6 blebs per patient were identified. The Endo-GIA30 was used for bullous resection in all patients. In five patients, the Endo-Clip also was used. An average of 2.5 Endo GIA30 staples per patient were required. The operative time was 44.6±11.6 min (range, 25 to 65 min). Postoperatively all patients returned to their rooms and could take food approximately 2 h following the operation. Postoperatively, minor complications were seen in 3 patients (9.4% ). In 2 patients, air leakage continued for more than 5 days. In 1 of these patients, air leakage stopped spontaneously 6 days after the operation. In the other patient, moderate air leakage continued, and 200 mg of minocycline hydrochloride dissolved in 50 ml of saline solution was instilled into the pleural cavity through a chest tube. Leakage stopped spontaneously in 48 h. In another patient, transient atelectasis of the affected side was seen on the c hest radiograph postoperatively. The atelectasis, however, was soon recovered. There were no other major or minor complications. The postoperative hospital stay ranged from 3 to 9 days, with a mean of 4.5 days. Patients were followed up for a total of 6 to 29 months. Recurrent ipsilateral pneumothorax occurred in 1 of the 32 patients (3.2%). This happened 3 months postoperatively, and the patient underwent a subsequent repair by thoracotomy. Table 3 shows comparative data on patients who were treated under local anesthesia and those treated under general anesthesia. Comparisons were made retrospectively between the two groups of patients. The average age and sex distributions were comparable between the two groups. The median operating time was significantly shorter for patients 44.6 ± 11.6 min in group 1 than for those in group 2 ( vs 63.3±20.1 min; p<0.01 ). The median postoperative hospital stay was also significantly shorter for those in group 1 than for those in group 2 ( 4.5 ± 1.3 days vs 5.8±1.1 days; p<0.01 ). The postoperative complication and recurrence rates were comparable between the two groups. DISCUSSION For many years, thoracoscopy has been used for the diagnosis of pleural lesions and diseases of the lung parenchyma. Many studies on large numbers of patients have confirmed the usefulness of thoracoscopic examinations under local anesthesia This method has become accepted as a relatively simple procedure and has proved effective and safe Table 3-Comparisons of Patients Undergoing Wedge Resections Under Local Anesthesia With Those Who Had General Anesthesia* Group l: Group 2: Local General Anesthesia Anesthesia No. of patients Age, yr 24.2:!:: :!:: 13.6 Male-to-fe male ratio 29:3 33:5 Operative time, min 44.6:!:: :!:: Chest tube duration, d 3.3:!:: :!::1.3 Complications, No. (%) 3 (9.4) 4 (10.5) Hospital stay, d 4.5::': ::':1.1 1 Recurrent pneumothorax, No. (%) 1 (3.1) 2 (5.3) *Results are the means::':sds. Complications in local anesthesia group we re air leakage in hvo and atelectasis in one, and those in the general anesthesia group were air leakage in three and atelectasis in one patient. 1 Significantly different from group 1 value ( p <0.01 ). CHEST I 111 I 1 I JANUARY,

5 Recently, video-assisted thoracoscopic surge1y (VATS) has evolved with increased use by thoracic surgeons. Traditionally, this procedure has been performed under general anesthesia, using doublelumen intubation. 6-8 To simplify the thoracoscopic surgery, we have tried to perform a thoracoscopic wedge resection with an Endo-GIA stapler under local anesthesia with IV sedatives. We included fibrin glue pleurodesis within our procedure to prevent the postoperative air leakage. Although this pleurodesis technique does not seem to be used routinely in the United States, it is not so uncommon in Europe 2 14 or Japan. Thoracoscopic surgery under local anesthesia has several advantages. The risks from general anesthesia or double-lumen intubation, although very few, can be avoided. Furthermore, oral intake can be resumed within a few hours following surgery. Postoperative recovery is faster, in general, with this procedure. To reduce local pain secondary to parietal pleural manipulation, we injected 0.5% lidocaine into the pleural space prior to surgery. Butorphanol tartrate and diazepam were also given IV. During the operation, all patients could respond to voice calls adequately, although they were a little drowsy. Only a few patients complained of cough when the forceps touched the parietal pleura. A questionnaire survey conducted following surgery confirmed that all but two patients reported no pain or more than mild discomfort during the surgery. Thus, pain seems to be well controlled during the thoracoscopic wedge resection under local anesthesia vvith sedation. We selected patients with no pleural adhesions and with precise preoperative identification of the bleb location, in order that surgery could be performed easily without complex manipulations. The absence of pleural adhesions could be confirmed by a preoperative air infusion test. The location of blebs was determined preoperatively by chest radiograph and CT scans of the chest. These locations could be confirmed immediately following insertion of the thoracoscope. It is quite easy to control the expansion and collapse of the lung by using a valved port with an insufflation stopcock. Blebs therefore could be resected with ease using a stapler (Endo-GIA). The average operating time for the thoracoscopic procedure was shorter than that for wedge resections performed under general anesthesia (Table 3). We considered at first that ventilation and hemodynamics might be affected adversely by pulmonary collapse during local anesthesia with sedation. Accordingly, we monitored Sa0 2 in all patients and demonstrated only slight changes. Our findings are consistent with those of Oldenburg and Newhouse, 12 who demonstrated a maximum mean fall in Sa0 2 of 1.4% during a diagnostic procedure under local 234 anesthesia. However, they reported some further transient desaturation (lowest oxygen saturation 83% without supplementary oxygen). Positioning the patient in the lateral decubitus position with the affected hemithorax on the topside helps to minimize any changes in the ventilation-perfusion disturbance. vve recommend monitoring oxygen saturation percutaneously and employing supplementary oxygen routinely during thoracoscopic surgery under local anesthesia. No cardiac arrhythmias were observed in our series, and this fact also parallels the results of other studies involving thoracoscopy under local anesthesia The success rate of this procedure, the rates of postoperative complications and the recurrence of the diseases, and the duration of hospital stay are all matters of concern. The operation was successful in 32 of 34 patients giving a 94% success rate. Within these 32 cases, only 1 patient suffered from the recurrence. Although two other patients had postoperative air leakage for several days, they were cured either spontaneously or by the additional chemical pleurodesis. Another patient had a transient atelectasis. We counted these three patients as successful cases because their complications were minor. Therefore, 91% of tl1e patients were successfully treated by this procedure. A tube drainage was conducted prior to surgery for more than 7 days, which resulted in the failure of spontaneous healing in patients with initial episode of pneumothorax in this series. The other patients had multiple episodes of pneumothorax. Thus, our success rate is better than that by a simple drainage since the recurrence rate of pneumothoraces after simple tube drainage is reported to be 25 to 50% for the initial cases and more for the repeated cases.i6-18 In the present series, the success rate of this technique was also comparable with the VATS under general anesthesia in our as well as others' experience.7 8 A shorter hospital stay following the present procedure than that after VATS under general anesthesia is beneficial. Although the success rate of our procedure was less than that for the standard thoracotomy by 5 to 6%, we believe that this procedure is still useful because of its minimal invasive intervention and short hospital stay. In conclusion, thoracoscopic wedge resection for the treatment of spontaneous pneumothorax under local anesthesia with sedation can be performed safely and beneficially because of overall shorter hospital stay and less invasion. We believe that this technique may further simplify thoracoscopic surgery as a definitive treatment of spontaneous pneumothorax. Minimally Invasive Techniques

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