Bilateral Simultaneous Pleurodesis by Median Sternotomy for Spontaneous Pneumo thorax I. Kalnins, M.B., T. A. Torda, F.F.A.R.C.S,, and J. S. Wright, F.R.A.C.S. ABSTRACT Bilateral pleurodesis by median sternotomy was performed in 26 patients with recurrent spontaneous pneumothorax. Sixteen of these patients had a history of bilateral pneumothorax. At operation, evidence of bilateral cystic abnormalities of the lungs was detected in all patients except 1. The technique and possible place of median sternotomy and bilateral pleurodesis are discussed. S pontaneous pneumothorax is a condition which has a strong tendency to recur [l, 41. In the past two years a number of patients admitted to this unit with recurrent spontaneous pneumothorax have been treated by median sternotomy and bilateral pleurodesis. The case histories of 26 patients treated in this way were reviewed to determine whether there is sufficient indication to continue with this procedure as a rational means of treatment. The place of such treatment was originally suggested by the occurrence of contralateral pneumothorax in 6 of 41 patients who had previously undergone unilateral surgical pleurodesis. The relative frequency of bilateral pneumothorax (about 20% in our previously reported group) [4], the almost universal finding of bilateral cysts at the time of these operations, and our experience with 4 patients (2 of whom died) who had simultaneous bilateral pneumothorax have caused us to continue with bilateral simultaneous pleurodesis in selected patients. Case Material and Findings The age distribution of this group of 26 patients was between 19 and 44 years with a mean of 28 years. There were 20 men and 6 women. Sixteen patients had experienced symptoms of pneumothorax on both sides of the chest. From the Divisions of Cardio-thoracic Surgery and Anaesthesia, the Prince Henry and Prince of Wales Hospitals, Sydney, Australia. Accepted for publication Sept. 26, 1972. Address reprint requests to Dr. Wright, Chairman, Cardio-thoracic Surgery, Prince Henry Hospital, Little Bay, N.S.W. 2036, Australia. 202 THE ANNALS OF THORACIC SURGERY
Bilateral Simultaneous Pleurodesis CORRELATION OF SYMPTOMS WITH OPERATIVE FINDINGS IN 26 PATIENTS UNDERGOING BILATERAL SIMULTANEOUS PLEURODESIS BY MEDIAN STERNOTOMY FOR SPONTANEOUS PNEUMOTHORAX Symptoms and Findings No. of Patients Symptoms Bilateral 16 Unilateral 10 Operative findings Bilateral lesions 25 Unilateral lesions 1 At operation, 25 patients had demonstrable lung abnormalities on both sides. There was only 1 patient whose lesions were confined to the symptomatic side (Table). In the majority, the lung lesions were in the form of small cysts or blebs near the apexes of the lungs. Rupture of one of these was presumed to be the site of air leak. In 2 patients there were localized bilateral pleural adhesions walling off cystic areas, and a further 3 patients showed nonadherent cysts on one side and apical pleural adhesions which were related to cystic lesions on the other. In 2 patients, in addition to the apexes of the lungs being involved with small cysts, there were also cysts extending along the peripheries of the lower lobes. One additional patient had cysts scattered along the whole of both upper lobe peripheries. Technique of Operation Bilateral pleurodesis was performed through a median sternotomy. Both pleural cavities were explored. Localized areas of lung cysts were obliterated by ligation with heavy braided silk, and pleurodesis was accomplished by abrasion of the parietal pleura followed by talc insufflation. Access to the pleural cavities is limited during median sternotomy, though in the young patient without extensive pleural adhesions, adequate exposure of the affected areas is available. Care is taken to protect the phrenic nerve on either side, and the upper few centimeters of the mediastinal reflection of the pleura are not divided so as to facilitate the positioning of an apical drainage tube on either side during chest closure. We have considered it important to perform cyst ligation conservatively so that the ligation involves the base of the cystic areas rather than normal lung adjacent to the cysts. Parietal pleurectomy was previously employed during unilateral pleurodesis but was abandoned due to problems of hemorrhage and doubt concerning its necessity. During the procedure of bilateral pleurodesis by median sternotomy, reliance has also been placed on pleural abrasion and talc poudrage alone. VOL. 15, NO. 2, FEBRUARY, 1973 203
KALNINS ET AL. Anesthetic Considerations In anesthetizing patients for pleurodesis, recurrence of the air leak, especially as a tension pneumothorax, is an ever-present danger. A previously placed intercostal catheter guards against tension on the drained side only, though such a catheter is not always present when the patient is operated upon. Furthermore, the occurrence of spontaneous pneumothorax is generally the result of bilateral disease, as has been pointed out. It is therefore generally considered safer to avoid positive-pressure ventilation until the pleural cavities are about to be entered [3]. Neuroleptic anesthetic techniques combined with topical anesthesia offer a safe and convenient alternative to deep inhalation anesthesia for induction and intubation with spontaneous ventilation, which can be assisted. It is not our practice to use compound endotracheal tubes for this procedure, but they are in no way contraindicated when the surgeon prefers them. In view of the bilateral nature of this disease, however, a technique using intermittent positivepressure ventilation applied only to the asymptomatic side cannot be considered to be free from hazard during the early part of the operation. In the postoperative period our patients receive no intermittent positivepressure therapy. Therefore, adequate analgesia is very important to help the patient perform the breathing exercises and coughing necessary to avoid sputum retention. Small doses of narcotic analgesics given at frequent intervals are preferable to larger doses more widely spaced. Because the incision involves six or more dermatomes, these patients should not receive postoperative epidural analgesia. Nonetheless, median sternotomy appears to be a less painful incision than lateral thoracotomy, and most patients so treated have had an accelerated convalescence compared with those having lateral thoracotomy. During lung reexpansion at the end of the surgical procedure, care must be taken to avoid producing pleural air leaks by rupture of other cysts or by dislodgment of cyst ligatures. A technique of progressive, gentle, intermittent positive-pressure ventilation should be used, with the accent on sustained, low-pressure inflations rather than on shorter, high-pressure ventilation. Results of Operation Convalescence appears to be more rapid and less painful with median sternotomy than after lateral thoracotomy, and full lung expansion has occurred in all patients. There have been no deaths and no significant complications. No patient has had a recurrence on either side. Occupational demands have been met more satisfactorily by the assurance of freedom from further pneumothorax on both sides. 204 THE ANNALS OF THCRACIC SURGERY
Comment Bilateral Simultaneous Pleurodesis Recurrent spontaneous pneumothorax is frequently bilateral. The average age for pneumothorax in this series was 28 years, similar to that in other series 11, 21. There were 10 patients who had no history suggestive of contralateral pneumothorax, yet at operation 9 of them were found to have lesions in the asymptomatic lung. Taken in conjunction with the rarity of apical bullae in a young autopsy population" and in young patients having thoracotomy for other reasons, this suggests that both lungs are at risk for pneumothorax in the patient group reviewed. Also, 6 of 41 patients have returned in the past two years with a pneumothorax on the opposite side after unilateral thoracotomy pleurodesis. Although it is difficult to draw any firm conclusion, it would seem that an increasing emphasis should be placed on simultaneous bilateral pleurodesis as an effective and definitive means for treating recurrent spontaneous pneumothorax, either unilateral or bilateral. Our indications for thoracotomy pleurodesis have been stated previously [4]. Our major ambition has been to eliminate the need for repeated periods of hospitalization and convalescence in patients with a propensity to recurrence or bilateral disorder. Failure of cessation of air leakage after a week, occupational or recreational hazards, and associated hemothorax constitute important additional indications. Early in our experience with management of voluminous bilateral emphysematous lung cysts, we undertook simultaneous bilateral cyst obliteration and pleurodesis in 2 elderly patients in whom extensive pleural adhesions were present. Adequate access was not available to those areas of adhesions related to the posterior and basal portions of the lungs. Accordingly, we have limited simultaneous bilateral pleurodesis to young patients having no history or evidence to suggest extensive pleural abnormalities or diffuse emphysematous lung conditions. Generally, bilateral pleurodesis has been avoided in young women for cosmetic reasons, although in the presence of a clear history of recurrent bilateral pneumothoraxes the bilateral procedure has been employed. Conclusions Spontaneous pneumothorax has a strong tendency to recur and to be bilateral in the younger group of patients affected. In the group reviewed here bilateral cystic lesions were the rule, notwithstanding a history of unilateral symptoms alone. Because of the occurrence of contralateral pneumothorax in young patients who previously had had unilateral pleurodesis, the relative frequency of symptomatic bilateral disorder, and the occasional finding of bi- *According to a study carried out by Dr. A. Tait Smith, Associate Professor of Pathology, University of New South Wales, Sydney, Australia. VOL. 15, NO. 2, FEBRUARY, 1973 205
KALNINS ET AL. lateral simultaneous pneumothorax, our current policy is to offer simultaneous bilateral pleurodesis by median sternotomy to young patients, particularly men, who have a history of repeated pneumothorax on one or both sides. Our operative findings have suggested that bilateral cystic lesions are extremely common. Cyst obliteration by ligation followed by pleural abrasion and talc insufflation has been associated with no recurrence over a period of more than two years and no mortality. Postoperative convalescence has been rapid and uneventful. References 1. Gobbel, J. N., Rhea, W. G., Nelson, I. A., and Daniel, R. A. Spontaneous pneumothorax. J. Thorac. Cardiovasc. Surg. 46:331, 1963. 2. Lindskog, G. E., and Halasz, N. A. Spontaneous pneumothorax. Arch. Surg. 75:693, 1957. 3. Mushin, W. W. Thoracic Anaesthesia. Oxford, England: Blackwell, 1963. 4. Watts, R. E., Bennett, D. J., Horton, D. A., and Wright, J. S. Spontaneous pneumothorax: A rational approach to treatment. Med. J. Aust. 1:538, 1970. Editor's Note: We realize that this paper may raise the hackles of many conservative thoracic surgeons. We would welcome any comments pro or con. 206 THE ANNALS OF THORACIC SURGERY