Primary spontaneous pneumothorax most commonly

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1 GENERAL THORACIC Salvage for Unsuccessful Aspiration of Primary Pneumothorax: Thoracoscopic Surgery or Chest Tube Drainage? Jin-Shing Chen, MD, PhD, Hsao-Hsun Hsu, MD, Kung-Tsao Tsai, MD, Ang Yuan, MD, PhD, Wen-Jone Chen, MD, PhD, and Yung-Chie Lee, MD, PhD Division of Thoracic Surgery, Department of Surgery, Department of Emergency Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, and Department of Emergency Medicine, Far Eastern Memorial Hospital, Taipei, Taiwan Background. Simple aspiration is recommended as first-line treatment for all primary spontaneous pneumothoraces requiring intervention. However, the optimal salvage treatment remains unclear when simple aspiration is unsuccessful for controlling symptoms. In this study, the safety, efficacy, and estimated costs of videoassisted thoracoscopic surgery (VATS) and chest tube drainage (CTD) were compared. Methods. Between 2002 and 2007, 164 patients with a first episode of spontaneous pneumothorax were managed by simple aspiration. Among them, 52 patients underwent subsequent VATS (30 patients) or CTD (22 patients) due to unsuccessful aspiration. The demographic data and treatment outcomes of the two groups were collected through retrospective chart review. Results. Postoperative analgesics use did not differ between groups. Complications developed in 2 of the VATS group (6.7%) and 6 of the CTD group (27.3%), with mean hospital stays of 4.8 and 6.1 days, respectively (p 0.034). Patients in the VATS group had lower rates of overall failure, although the rates of immediate failure were not significantly different. After a mean follow-up of 16 months, recurrent ipsilateral pneumothorax was noted in 1 VATS patient and 5 CTD individuals (p 0.038). The estimated total costs per patient were $1,273 in the VATS group and $865 in the CTD group. Conclusions. Although associated with higher costs, VATS rather than CTD is the preferred salvage treatment for unsuccessful aspiration of the first episode of primary spontaneous pneumothorax, because of shorter hospital stay and lower rates of overall failure and recurrence. (Ann Thorac Surg 2008;85: ) 2008 by The Society of Thoracic Surgeons Primary spontaneous pneumothorax most commonly occurs in young, tall, lean males [1, 2]. Optimal management for a first episode of this benign disease has been a matter of debate. In the recently published British Thoracic Society guidelines [3], simple aspiration is recommended as the first-line treatment for all primary pneumothoraces requiring intervention because it appears to be as effective as chest tube drainage (CTD), as well as safe, well tolerated, and feasible in an outpatient setting in the majority of cases [3]. When simple aspiration was unsuccessful, which occurred in about 15% to 62% of all pneumothoraces requiring intervention, chest tube drainage is recommended [3 12]. However, many prospective studies that have compared simple aspiration and tube drainage for primary spontaneous pneumothorax have shown that they are equally effective for treatment of primary spontaneous pneumothorax in terms of success and recurrence rates [4, 11, 12]. In this regard, CTD provides no benefits in unsuccessful aspiration of primary spontaneous pneumothorax because the rates of persistent air leakage and recurrence remain the same. Accepted for publication Feb 13, Address correspondence to Dr Lee, Department of Surgery, National Taiwan University Hospital, No. 7 Chung Shan South Rd, Taipei, 100, Taiwan; yclee@ntuh.gov.tw. Advances in video-assisted thoracoscopic surgery (VATS) have made it a safe, less invasive, and more effective intervention for treating recurrent pneumothorax or persistent air leakage after CTD [13 15]. However, the role of VATS in the management of first primary spontaneous pneumothorax where aspiration has failed remains unclear. Theoretically, unsuccessful aspiration is usually associated with large or persistent air leaks. Definitive treatment would include elimination of air leakage and, if possible, recurrence. Under such consideration, VATS with bullectomy and mechanical pleurodesis provides a good alternative in terms of achieving these therapeutic goals. Our study hypothesis was that VATS is more effective than CTD for management of primary spontaneous pneumothorax with aspiration failure. To this end, we compared two groups of patients who had experienced unsuccessful aspiration of primary spontaneous pneumothorax, stratified by treatment. Patients and Methods Study Design Since 2002, simple aspiration has been performed in our hospital as the initial management of primary spontaneous pneumothorax. When simple aspiration was unsuc by The Society of Thoracic Surgeons /08/$34.00 Published by Elsevier Inc doi: /j.athoracsur

2 Ann Thorac Surg CHEN ET AL 2008;85: VATS FOR UNSUCCESSFUL PNEUMOTHORAX ASPIRATION cessful, which was defined as persistent air leaks or pneumothoraces that failed to resolve after single or repeated aspiration, VATS or CTD was selected as the salvage treatment. The decision was made by the patient s willingness after thorough explanations by the attending physician. The indications for chest tube insertion or thoracoscopic surgery were identical, although the timings were different. Chest tube drainage was usually made immediately after failure of aspiration whereas VATS was introduced at least several hours or 1 day later owing to inadequate preoperative fasting time or no available operation room. In this retrospective study, the safety, efficacy, hospital stay, and estimated costs of VATS and CTD were evaluated and compared. The local Institutional Review Board approved the study and waived the requirement for informed consent the catheter in place. In cases of persistent air leaks or pneumothoraces that failed to resolve, aspiration might be repeated one or two more times. Chest Tube Insertion Chest tube drainage was performed using 24F to 28F plastic tubes (Argyle; Tyco Healthcare Group, Mansfield, Massachusetts) in the emergency department. The tube was inserted under local anesthesia at the anterior midclavicular second interspace, or at the fourth/fifth interspace at the midaxillary line. When the air bubbling stopped and complete lung expansion had been confirmed by chest plain x-ray film, the tube was removed on expiration. Patients were subsequently allowed to leave the hospital; those with prolonged air leakage or incomplete lung expansion were given further VATS treatment. GENERAL THORACIC Patient Selection All patients with the diagnosis of spontaneous pneumothorax admitted to the emergency department or general ward between January 2002 and June 2007 were identified. The setting was a 2,600-bed university teaching hospital with an emergency department annual census of approximately 100,000 patient visits. After careful review of the medical records, only patients who had undergone manual aspiration as their initial treatment were selected. To eliminate cases involving recurrent or secondary spontaneous pneumothorax, exclusion criteria included previous history of spontaneous pneumothorax, age more than 50 years, and preexisting pulmonary disease. Successful aspiration requiring no further management was an additional exclusion criterion. Only cases involving unsuccessful aspiration requiring further chest tube insertion or thoracoscopic surgery were enrolled. Estimation of Pneumothorax Size Each chest plain x-ray film was carefully reviewed and pneumothorax size estimated using Light s formula (estimated pneumothorax percentage (EPP) (1 L3/H3) 100; where, H mean hemothorax diameter and L mean diameter of the collapsed lung) [16]. Manual Aspiration Informed consent was obtained from all patients before the procedure. Manual aspiration was performed as follows: patients were seated in a semisupine position. After skin disinfection and field preparation, a smallcaliber (16G or 18G) Teflon intravenous needle catheter (Surflo; Terumo, Tokyo, Japan) or a small-caliber (6F or 8F) pigtail catheter (Bioteque, I-Lan, Taiwan) was introduced after local anesthesia in the second or third intercostral space, at the midclavicular line. After the catheter was inserted into the pleural space, it was fixed to the skin using sterile adhesive tape and connected through a three-way valve to a 50-mL syringe. Air was manually aspirated, until a resistance was felt and air was no longer aspirated. Chest radiography was then performed with Operative Technique of VATS Modified needlescopic VATS was performed in the standard fashion under general anesthesia using intubation with a double-lumen endotracheal tube, as described previously [17]. Briefly, the patients were placed in a lateral decubitus position, and the ipsilateral lung was deflated. Two sets of independent video-thoracoscopic equipment and monitors, one for needlescopic videothoracoscopy and the other for 10-mm videothoracoscopy, were used simultaneously. Basically, we used the 10-mm videothoracoscopy for most of the surgical steps. A needlescope was indicated only when we need the chest tube wound to insert the endoscopic stapler and ring forceps, to extract the specimen, or to perform pleural abrasion. A 10-mm 30-degree telescope (Karl Storz, Tuttlingen, Germany) was first inserted through a 12-mm port at the sixth or seventh intercostal space. Two 3-mm skin incisions were made at the third or fourth intercostal space, and anterior and posterior axillary line. Light pleural adhesions were freed using electrocautery. When blebs were identified, they were grasped with the needlescopic dissectors and excised with a 45-mm endoscopic stapler. Blind apical stapling was done at the most suspicious area if no bleb could be identified. The entire parietal surface was abraded by inserting the dissector with a strip of diathermy scratch pad through the port sites. After postoperative lung reinflation, normal saline solution was instilled to check for air leaks. A chest tube (28F) was placed in the apex through the 12-mm wound. The surgical specimens were routinely sent for pathology examination. After the operation, minocycline pleurodesis was randomly administered to 50% of the patients according to our clinical trial protocol [18]. Analgesics Postprocedural analgesia was achieved using routine oral nonsteroidal analgesics and acetaminophen. Intramuscular meperidine hydrochloride (Demerol, 50 mg/amp) was administered every 4 to 6 hours on demand if the pain became intolerable or could not be relieved by oral analgesics.

3 GENERAL THORACIC 1910 CHEN ET AL Ann Thorac Surg VATS FOR UNSUCCESSFUL PNEUMOTHORAX ASPIRATION 2008;85: Cost Estimation Management costs were made by taking into account the total costs of the first and subsequent hospital stays for treatment of pneumothorax and late recurrence. Because the detail costs for some patients were not available, the estimation was made according to the tariffs of Taiwan s Bureau of National Health Insurance. Data Collection and Analysis The data, including patient demographics, radiographic size of pneumothorax, accumulated dose of meperidine, durations of hospital stay, complications, and results, were collected through retrospective chart review and documentation of information in the database. Patients were followed up for at least 3 months during clinical visits or by telephone conversation to evaluate whether a recurrence occurred, when it happened, and how it was treated. Immediate failure was defined as incomplete lung expansion owing to malposition of the chest tube or prolonged air leakage ( 72 hours) requiring additional procedures in the CTD group, or as prolonged air leakage ( 72 hours) in the VATS group after the operation. Overall failure was defined where additional procedures were required owing to prolonged air leakage or pneumothorax recurrence in the CTD group, or pneumothorax recurrence in the VATS group, during the whole follow-up period. Continuous variables such as age and body weight were expressed as mean SD, with the two-sample t test used for statistical analysis. Categorical variables such as sex and smoking status were presented as frequencies (%), and the Fisher s exact test was used for analysis. Number of aspirations was expressed by median (range) and analyzed by the Wilcoxon rank-sum test. The Kaplan-Meier method was used to analyze freedom from recurrence, with the log-rank test used for comparisons. A p value of less than 0.05 was considered significant for all tests. Results Between 2002 and 2007, a total of 164 patients with spontaneous pneumothorax were managed by simple Table 1. Clinical Characteristics of Patients With Unsuccessful Aspiration VATS (n 30) CTD (n 22) p Value Age, years a Males, number (%) 25 (86.5%) 20 (90.9%) Body mass index a Smoking, number (%) 15 (50.0%) 8 (36.4%) Left side involved, number (%) 16 (53.8%) 10 (45.5%) Number of aspirations, median 2 (2 3) 2 (1 3) (range) Pneumothorax size, percent a,b a Mean SD. b Seventeen patients in the CTD group and 27 in VATS group were available for estimation by Light s formula. CTD chest tube drainage; VATS video-assisted thoracoscopic surgery. Table 2. Treatment Results of Patients With Unsuccessful Aspiration VATS (n 30) CTD (n 22) p Value Meperidine requested, 15 (50.0%) 9 (42.3%) number (%) Dose of meperidine, mg a Complications, number (%) 2 (6.7%) 6 (27.3%) Prolonge air leaks 2 (6.7%) 4 (18.2%) Chest wall hematoma 0 (0%) 1 (4.5%) Malposition of chest tube 0 (0%) 1 (4.5%) First hospital stay, days a Immediate fail rate, 2 (6.7%) 5 (22.7%) number (%) Overall fail rate, number (%) 1 (3.3%) 9 (40.9%) Recurrence, number (%) 1 (3.3%) 5 (22.7%) Total hospital stay, days a,b a Mean SD. b Including first and subsequent hospital stays for treatment of pneumothorax and late recurrence. CTD chest tube drainage; VATS video-assisted thoracoscopic surgery. aspiration using pigtail (n 122) or intravenous needle catheter (n 42) at our emergency department. Of these, 112 patients were excluded because of age more than 50 years (n 2), preexisting pulmonary diseases (n 1), or successful aspiration (n 109). The remaining 52 subjects underwent VATS (n 30) or CTD (n 22) because of persistent air leakage or failed pneumothorax resolution after single or multiple aspiration. The failure rate for simple aspiration in the primary spontaneous pneumothorax patients was 32.3% (52 of 161). There was no significant difference between the two groups in terms of age, sex, body mass index, smoking status, side involvement, number of aspirations, or pneumothorax size (Table 1). The treatment results are summarized in Table 2. Although local anesthesia and oral analgesics were given, wound pain remained the most common complaint after chest tube insertion and thoracoscopic surgery. Fifteen patients (50.0%) in the VATS group and 9 patients (42.3%) in the CTD group requested meperidine injection. The mean accumulated dose of meperidine was not significantly different between the two groups. Immediate failure occurred in 2 patients (6.7%) in the VATS group because of prolonged air leaks. One of them underwent minocycline instillation through the chest tube, and the other patient was managed conservatively. In the CTD group, immediate failure occurred in 5 patients (22.7%), including prolonged air leaks in 4 patients and malposition of the chest tube in 1 patient. The 4 patients with prolonged leaks underwent subsequent VATS for definitive treatment. The patient had malposition of the chest tube undergoing reposition of the tube. Chest wall hematoma developed in 1 patient in the CTD group after chest tube insertion and was managed conservatively. Blood transfusion was not required in any of our patient. No patients had pleural empyema. The mean stay of the first hospitalization was days in the VATS group and days in the CTD group (p 0.034).

4 Ann Thorac Surg CHEN ET AL 2008;85: VATS FOR UNSUCCESSFUL PNEUMOTHORAX ASPIRATION Table 3. Estimated Management Costs per Patient a VATS 1911 CTD Hospital stay b (1 day $55) $270 $396 Procedure and material expenditure VATS c ($810) $810 $295 CTD d ($105) $3 $105 General anesthesia c ($190) $190 $69 Total $1,273 $865 GENERAL THORACIC a Including first and subsequent hospital stays for treatment of pneumothorax and late recurrence. b Hospital stay was 4.9 days in the VATS group and 7.2 days in the CTD group. c Eight of 22 CTD patients (36.4%) underwent VATS and general anesthesia. d One of 30 VATS patients (3.3%) underwent CTD. CTD chest tube drainage; VATS video-assisted thoracoscopic surgery. Fig 1. Freedom from recurrent pneumothorax in patients undergoing video-assisted thoracoscopic surgery (VATS) or chest tube drainage (CTD). The number of patients at risk for each 6-month period is indicated under the corresponding time point. After a mean follow-up of 16 months (range, 3 to 38), recurrent ipsilateral pneumothorax was noted in 1 of the VATS group (3.3%) and 5 of the CTD group (22.7%). The rates of freedom from recurrence, as determined using the Kaplan-Meyer method, for both groups are plotted in Figure 1, with log-rank test comparison. Patients who underwent VATS had a significantly lower rate of ipsilateral recurrence than analogs treated with CTD (p 0.038). The recurrent patient in the VATS group underwent chest tube insertion and minocycline pleurodesis. Four of the 5 recurrent patients in the CTD group underwent VATS bullectomy and pleural abrasion to prevent further recurrence. The remaining patient had a small pneumothorax that resolved spontaneously after oxygen therapy was provided. The algorithm for patient selection, treatment allocations, and outcome is summarized in Figure 2. Overall failure requiring subsequent additional treatment occurred in 9 patients in the CTD group (41%, 4 prolonged leaks requiring VATS and 5 recurrences) but only 1 patient in the VATS group (3%, recurrence; p 0.001). The mean total hospital stay, including the first and subsequent hospitalization, was days in the VATS group and days in the CTD group (p 0.005). The estimated total costs per patient were $1,273 in the VATS group and $865 in the CTD group (Table 3). Fig 2. Flow chart representation of patient selection, treatment allocations, and outcome. (CTD chest tube drainage; VATS video-assisted thoracoscopic surgery.)

5 GENERAL THORACIC 1912 CHEN ET AL Ann Thorac Surg VATS FOR UNSUCCESSFUL PNEUMOTHORAX ASPIRATION 2008;85: Comment This is the first comparison study of VATS and chest tube drainage as salvage treatments in a homogenous population of patients presenting with a first episode of primary spontaneous pneumothorax where simple aspiration had failed. We demonstrated that VATS is a safe and effective salvage treatment where simple aspiration has been unsuccessful. In contrast, CTD is not recommended in these cases because of the prolonged hospital stay and higher rates of recurrence and overall failure. There seems to be a general consensus with respect to adopting a conservative approach to cases involving a first episode of primary spontaneous pneumothorax when the patients are asymptomatic and the pneumothorax is small. The choice of initial management for primary spontaneous pneumothorax requiring intervention, however, has remained controversial. Choices include simple aspiration, CTD with or without sclerosis, and VATS [3, 13, 19 21]. Although previous studies have shown that VATS or talcage through medical thoracoscopy is more cost effective than CTD in treating first episode of primary pneumothorax [20 22], these options are not widely accepted because 70% of the surgeries have been unnecessary. Until now, there has been quite good consensus that treatment of a first episode of primary spontaneous pneumothorax should simply consist of simple air removal and not prevention of recurrence [3, 13]. Regarding air removal, simple aspiration is considered as the preferred method for the initial management of primary spontaneous pneumothorax because several studies revealed that simple aspiration is as effective as chest tube drainage, with reduced morbidity, hospital stay and the need for hospitalization [10 12, 23]. However, unsuccessful simple aspiration was encountered in 32% of our patients and salvage procedures were required for them. The failure rates of simple aspiration for primary spontaneous pneumothorax are widely varied in the literature, ranging from 15% to 62% [3 12]. According to the British Thoracic Society guidelines, if simple aspiration is unsuccessful in controlling symptoms, then a chest tube should be inserted [3]. However, the reported success and recurrence rates for CTD are similar to those for simple aspiration, making chest tube insertion an unsatisfactory salvage procedure in cases of failed aspiration. In addition, failed salvage procedures inevitably and unnecessarily increases the length of stay, and it creates more procedure-related anxiety and discomfort. Hence, the selection of optimal salvage procedure is very important. In this study, VATS was selected as the salvage procedure because it provides a safe and secure way to seal the air leaks and is also effective in preventing pneumothorax recurrence. Although CTD can be performed with local anesthesia and it appears to be less invasive compared with VATS, the associated complication rates for the former (27%) were not low in our study. In addition to prolonged air leakage, complications also included chest wall hematoma and tube malposition. The difference in complication rates between the two groups was of borderline statistical significance; however, this was probably due to the small sample size. The high CTD complication rates may partially be attributed to the procedures being performed in the emergency department by inexperienced junior doctors, often under less-controlled circumstances [24, 25]. In contrast, VATS was performed by experienced surgeons in the operation theater under well-controlled condition with a clear, magnified view of the surgical field. It appears reasonable to conclude, therefore, that technique-related complications would be reduced. Chest pain was also very common in the CTD group and the incidence and dose of requested meperidine between the two groups was comparable. Possible explanations are that chest tube insertion is a painful procedure and local anesthesia is not sufficient to relieve pain and stress, and that VATS was used in this study, which may have reduced chest wall trauma compared with the conventional form. The mean first and total hospital stays for our CTD group was significantly greater compared with the VATS group. The results of this study are consistent with previous reports that show that immediate treatment of spontaneous pneumothorax with VATS is associated with a shorter hospital stay compared with CTD [20, 21]. When costs are compared, however, the shorter hospital stay of VATS did not translate into economic saving benefits because the estimated costs per patient in the VATS group is 32% higher. The main reasons have included that VATS is an operative procedure requiring general anesthesia and endoscopic instruments, and that the tariffs of the hospital stay is very inexpensvie in Taiwan when compared with expenditure of general anesthesia, operative procedure, and endoscopic instruments (Table 3). Previous studies have shown that the recurrence rates after pleural drainage were rather high, varying from 25% to 34% [10 12, 19]. In our study, we confirmed this finding, demonstrating a recurrence rate of 23% after chest tube drainage. The overall failure rate in the CTD group is also high (41%), indicating that subsequent procedures are commonly required because of prolonged air leaks or presence of recurrent pneumothorax. In contrast, our study showed that VATS provided decreased rates of recurrence and overall failure. In addition to cost and effectiveness, psychological factors are also important and should be taken into consideration when choosing a salvage treatment after a failed procedure. At present, when aspiration is unsuccessful, we are obliged to inform the patient of the 23% and 41% probabilities of immediate and overall failure, respectively, for CTD, and that prolonged hospital stay or additional admission for another surgical procedure may be required. Obviously, this information is a psychological stress for the patient, who must cope with the prospect of another failed procedure or return admission, as well as alterations to lifestyle and social activities for fear of recurrence. By contrast, patients who have undergone VATS are secure in the knowledge that the inter-

6 Ann Thorac Surg CHEN ET AL 2008;85: VATS FOR UNSUCCESSFUL PNEUMOTHORAX ASPIRATION vention should be both definitive and effective, and that they can expect a rapid resumption of normal social life. We acknowledge that this is a retrospective study, and that the case number is not large. Nevertheless, our results suggest that CTD may not be a good alternative, from both practical and psychological perspectives, when aspiration has failed and a salvage procedure is required. In contrast, VATS appears to be a safe and effective procedure associated with decreased hospital stay, as well as lower rates of overall failure and pneumothorax recurrence, although the cost is higher. It seems reasonable to suggest, therefore, that it should be promptly applied as the initial treatment for primary spontaneous pneumothorax where aspiration has failed. This study was supported by a research grant from the Department of Health, Taiwan (DOH95-TD-I ). References 1. 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