|Year : 2020 | Volume
| Issue : 3 | Page : 540-545
Video-assisted thoracoscopic bullectomy with pleurectomy versus pleural abrasion in the treatment of primary spontaneous pneumothorax
Rezk Zenhom Abogamila
MD degree of Cardiothoracic Surgery; Department of Cardiothoracic Surgery, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
|Date of Submission||02-Jul-2020|
|Date of Decision||08-Jul-2020|
|Date of Acceptance||20-Jul-2020|
|Date of Web Publication||2-Oct-2020|
MD Rezk Zenhom Abogamila
MD degree of Cardiothoracic Surgery; Department of Cardiothoracic Surgery, Faculty of Medicine for Girls, Al-Azhar University, Cairo,
Source of Support: None, Conflict of Interest: None
Background Comparative study between partial pleurectomy and mechanical pleural abrasion in the treatment of primary spontaneous pneumothorax (PSP) by video-assisted thoracoscopy (VATS) to show its efficacy and safety.
Patients and methods Between August 2014 and January 2018, 120 patients with PSP underwent VATS pleural abrasion and partial pleurectomy with bullectomy for both groups in the Security Force Hospital, Riyadh, KSA. All patients were reviewed retrospectively according to medical records.
Results Partial pleurectomy was performed in 60 (50%) patients while other 60 patients underwent pleural abrasion. There is no significant differences in sex, age, weight, or history of smoking at the time of surgery. There was longer operative duration in the pleurectomy group (90±12.4 min) versus the pleural abrasion group (40±7.55 min) but with more blood loss in the latter one (P<0.001). There was no significant differences between studied groups regarding number, site, and size of bullae (P>0.05). There was no significant difference in major postoperative complications (P=0.132). Nine (7.5%) patients developed pneumothorax after surgery with mechanical pleurodesis. The incidence of recurrent pneumothorax in patients who underwent pleural abrasion was higher than in patients who underwent pleurectomy (13.3 vs. 1.7%, P=0.045).
Conclusion In our study, VATS pleurectomy is more effective in the treatment of PSP than pleural abrasion. The recurrent rate of pneumothorax is significantly lower in the pleurectomy group than in the pleural abrasion group. So, VATS pleurectomy is the procedure of choose in the management of PSP.
Keywords: abrasion, pleurectomy, spontaneous pneumothorax, thoracoscopy
|How to cite this article:|
Abogamila RZ. Video-assisted thoracoscopic bullectomy with pleurectomy versus pleural abrasion in the treatment of primary spontaneous pneumothorax. Sci J Al-Azhar Med Fac Girls 2020;4:540-5
|How to cite this URL:|
Abogamila RZ. Video-assisted thoracoscopic bullectomy with pleurectomy versus pleural abrasion in the treatment of primary spontaneous pneumothorax. Sci J Al-Azhar Med Fac Girls [serial online] 2020 [cited 2020 Oct 26];4:540-5. Available from: http://www.sjamf.eg.net/text.asp?2020/4/3/540/296962
| Introduction|| |
Definition of primary spontaneous pneumothorax (PSP) is the presence of air in the pleural cavity without any underlying pulmonary disease. The incidence of PSP was reported as 18–28/100 000 in men and 1.2–6/100 000 in women, ∼1.2–18/100 000 in population .
Treatment of PSP depends on many factors such as patient’s clinical presentation, the size of the pneumothorax, and history of previous attacks . Treatment include monitoring under oxygen therapy, needle aspiration, tube thoracostomy, and surgical operation ,.
There are a number of commonly accepted surgical approaches for the treatment of PSP ,. In general, a resection of bullae and numbers of bleb structures with a pleurodesis procedure. Although some studies used other agents such as talc powder and minocycline for pleurodesis, there are also other studies that recommend pleural abrasion or partial/total pleurectomy ,,,.
So, this study compares the efficacy and safety of partial or complete pleurectomy and mechanical pleural abrasion in the management of PSP by performing video-assisted thoracoscopy (VATS).
| Patients and methods|| |
Between August 2014 and January 2018, 120 patients underwent surgery for spontaneous pneumothorax in the Security Force Hospital (SFH), Riyadh, KSA. All patients consented before operation. The study was approved and reviewed by the Committee for SFH.
Patients complaining of secondary PSP (i.e. diffuse emphysema, catamenial pneumothorax, or pulmonary lymphangioleiomyomatosis) were excluded. Indication for surgery of recurrent PSP (100 patients, 83.3%) or first attack of pneumothorax with prolonged air leakage for more than 5 days (20 patients, 16.7%) during the first attack of PSP.
Patient characteristics including sex, age, BMI, smoking habit, method of pleurodesis, duration of chest tube duration, operative time, duration of hospital admission, postoperative complications, recurrence of pneumothorax after surgery, and follow-up for 1 year were collected retrospectively.
Under general anesthesia, ventilation with double-lumen intubation. The patient was placed in the posterolateral position. Single-lung ventilation was started before skin incision. A 0°, 10-mm videothoracoscope was introduced through the port and the pleural cavity was inspected. Two other ports were then placed under direct endoscopic visualization in the six anterior and seven posterior intercostal spaces. The apex of the lung was grasped with an endograsp and all aspects of the lung were inspected. Blebs or bullae were excised with an endoscopic linear stapler EndoGIA; saline solution was instilled into the pleural cavity and the lung ventilated to detect any air leak.
Pleurodesis was done by vigorous pleural abrasion using a part of wide-mesh polyglycolic acid grasped to the tip of a standard endoscopic grasper. The parietal pleura and diaphragm were abraded by inserting the grasper successively to the opening of three ports. Abrasion was stopped when the bloody pleura was obtained. One chest tube was placed through the anterior incision of the port and allow the lung to re expand. The chest tubes were connected to an underwater seal and suction with a negative pressure of 20 cmH2O, for the first 24 h.
Pleurectomy was performed by dissection between the partial pleura and the internal muscle of the chest wall and inner aspect of ribs starting at the site of the thoracoport, by a small piece of gauze on grasper. The most important aria should be removed is the aria of the apex, the anterior and posterior partial pleura, two chest tubes inserted in the pleural cavity and connected on low-grade suction for first 24 h, after which the suction is disconnected.
Any surgical specimen was systematically sent to the histopathological department.
The parameters included the percentage and number of the various modalities. Data were expressed as mean±SD and median (range). Comparison of the difference of recurrent attacks between groups was done by using the χ2 test or Fisher’s exact test, whichever is applicable. P values less than 0.05 were considered to indicate statistical significance. The analyses and statistics were evaluated by using SPSS software, version 23.0 (IBM Corp., Armonk, New York, USA).
| Results and baseline characteristics|| |
Between August 2014 and January 2018, 120 patients underwent VATS pleural abrasion with bullectomy or pleurectomy as a surgical treatment for PSP at SFH. Patient demographics were comparable between the groups as detailed in [Table 1]. Regarding the affected side, 70 and 50 patients complained of PSP on the left side (32 and 38 in pleural abrasion and pleurectomy groups, respectively), and 50 patients complained of PSP on the right side (28 and 22 in pleural abrasion and pleurectomy groups, respectively). Ninety patients presented with chest pain and 30 patients presented with dyspnea. Of the number of PSP occurrences prior to surgical treatment, 20 (16.7%) patients and 22 (83.3%) patients had two or more attacks of recurrent PSP. There was no significant difference in demographics and preoperative clinical data between the two groups ([Table 1]).
We found longer operative duration in the pleurectomy group (90±12.4 min) versus pleural abrasion group (40±7.55 min), but with more blood loss in the last one (P<0.001). There was no significant differences between the two groups regarding number, site, and size of bulla and blebs (P>0.05).
Also, we found significantly the duration of chest tubes placed at the end of the procedure in patients undergoing pleurectomy than pleural abrasion (P=0.021). Median range of drainage duration of chest tube was 4.2±2.12 days in the pleurectomy group and 2.11±1.02 days in the pleural abrasion group with significant difference between both groups (P<0.001). There was significantly larger amounts of drainage by a chest tube in the pleurectomy group (600±200 ml) compared with the pleural abrasion group (300±100 ml) (P<0.001). Length of hospital stay was 5.5±2.6 in the pleural abrasion group versus 6.1±1.8 days in the pleurectomy group with no significant difference between the two groups (P=0.144) ([Table 2] and [Figure 1]).
|Figure 1 (a) Radiograph chest RT spontaneous pneumothorax, (b) computed tomography chest RT pneumothorax with apical bulla, (c) bullectomy, (d) thoracoscopic picture of multipole bulla, (e) bulectomy with a stapler, and (f) pleurectomy.|
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Postoperative course, a total of 10 (16.7%) patients in the post-pleurectomy group show the following complications. Two (3%) patients had prolonged air leakage, two (3%) patients developed Horner’s syndrome that disappear spontaneously within 2 months’ postoperatively and two (3%) patients developed signs of infection in the wound treated with antibiotics. Three (5%) patients were with major complications (hemothorax), only one patient had recurrence requiring rethoracoscopy and one (1.7%) patient with atelectasis was treated by bronchoscopy. In the pleural abrasion group, there were six (10%) patients with complications; one (1.7%) patient had prolonged air leakage and five (8.3%) patients had minor complications (infection) that were all successfully treated with medical treatment in the form of antibiotics.
Nine (7.5%) patients had recurrent attacks of pneumothorax after surgical pleurodesis. Incidence of recurrent attacks in those undergoing pleural abrasion was significantly more than those undergoing pleurectomy (8/60 vs. 1/60, P=0.045).
There was no hospital or 90-day mortality following any of the both groups ([Table 3]).
| Discussion|| |
In PSP, the lowest recurrence rate of PSP with open thoracotomy and pleurectomy remains the best procedure . So, it is still the recommended procedure in the management of guidelines in the British Thoracic Society .
The VATS procedure has higher recurrence attacks of PSP with its advantages like, less pain, less surgical time, less hospital stays, and early recovery postoperatively after thoracic surgery; therefore, an increasing number of surgeons choose a minimally invasive approach via (VATS) surgery for the management of PSP ,,,.
In another study, we found longer operative time and drainage durations of chest tube and more amounts of drainage by a chest tube in the pleurectomy group compared with the pleural abrasion group with significant difference between the two groups (P<0.001). In agreement with our results, Lochowski et al.  revealed that patients with the pleurectomy group had more postoperative drainage of blood than patients with post-pleural abrasion (on average 323.8 vs. 199.3 ml, P=0.068), but the average duration of drainage in both groups was the same (pleurectomy group vs. pleural abrasion: 4.3 vs. 4.0 days, P=0.27).
Kocaturk et al.  the duration of postoperative chest tube drainage time in the pleurectomy group was less than in the pleural abrasion group and short duration of hospital stay after pleurectomy compared with pleural abrasion, which was not seen in our study where the length of hospital stay was shorter in the pleural abrasion group (5.5±2.6 days) compared with 6.1±1.8 days in the pleurectomy group, but with no significant difference between the two groups (P=0.144).
In the Chen et al.  study a group of 369 patients showed a more amount of intraoperative blood loss (P=0.025) than postoperative blood loss (P=0.04) in patients who underwent pleurectomy.
This study showed that postoperatively, 10 (16.7%) patients in the post-pleurectomy group were with the following complications: prolonged duration of air leakage, Horner’s syndrome, signs of infection treated medically, hemothorax that required reoperation by VATS, and atelectasis treated by bronchoscopy. In the pleural abrasion group, of the six (10%) patients, one (1.7%) patient had prolonged air leakage and five (8.3%) patients had minor complications such as wound infection that were all successfully treated with medical treatment. But both groups show no differences in postoperative complications. These findings were in agreement with the conclusion of Chen et al.  in their study.
In the study done by Huh and colleagues on a group of 207 patients in 2012, there was no differences in air leakage for pleurectomy and pleural abrasion groups.
In the Lochowski et al.  study, complications occurred in eight (6%) patients; in two cases, there was bleeding (pleurectomy group), which was treated conservatively and of the six cases, two (4.8%) were in the pleurectomy group and four (4.9%) in the pleural abrasion group, persistent air leak, stopped within 6–10 days postoperatively. There were three (2.4%) recurrences, one in the pleurectomy group and two in the pleural abrasion group (time of observation from 1 to 10 years), which matched with our study.
Among the complications connected with pleurectomy, damage to the brachial plexus and the Horner syndrome is also described by Skoro et al. . That complication was observed among two patients who underwent pleurectomy (3%) which agrees with our result.
In our study, hemothorax was treated conservatively in 5% of patients who underwent pleurectomy. VATS pleurectomy can be the cause of bleeding as described by Gómez-Caro et al. , and Imperatori et al. .
Regarding postoperative bleeding complications, detected by observing the type of drained fluid rather than the amount of fluid drained by a chest tube, there was longer time of postoperative chest drain duration in the pleurectomy group compared with the other group .
To reduce the risk of bleeding, we now spare the area of internal mammarian subclavian arteries in the apex during pleurectomy. We do a meticulous hemostasis at the thoracic wall using a bipolar forceps to any point showing active bleeding during operation.
The rate of major complications in our study is comparable to other published series. But the postoperative blood loss in our study is slightly more than other studies because the aria of subclavian artery and mammarian arteries are not spared. And there is no significant bleeding from both arteries ,,,.
Regarding the rate of recurrence pneumothorax post-surgical pleurodesis, the recurrent attacks of PSP in the group that underwent pleural abrasion was significantly higher than those undergoing pleurectomy (13.3 vs. 1.7%, P=0.045). In agreement with our study, Bille and colleagues, showing different procedures for pleurodesis affect the recurrence rate of PSP. They concluded that the recurrences rate with pleural abrasion patients was higher, than the pleurectomy group which was not significant.The study done by Huh and colleagues on a group of 207 patients in 2012  showed a more rate of recurrent attacks of PSP in patients who underwent pleural abrasion.
Against our study, the Kocaturk and colleagues study that compared pleural abrasion with pleurectomy revealed a significant reduction of pneumothorax after pleurectomy. The type of surgical access results are comparable to our findings.
So, the minimally invasive procedure had excellent results than other procedures.
The review by Ling and colleagues did a comparative study between pleural abrasion and pleurectomy and other interventions in the management of PSP. This study concluded that pleurectomy and pleural abrasion shows more frequent complication and postoperative pain.
In a systemic review, Joharifard et al.  had a significant reduction in recurrent attacks of pneumothorax after pleurectomy group compared with the pleural abrasion group in a pediatric patient. This study also shows higher recurrent attack rates of PSP in pleural abrasion (40%).The causes of higher recurrence rate in this study are not clear, and there is no other factor different between the two groups except the method of surgical pleurodesis.
In the Ng et al.  study, 8.4% of patients had recurrent attacks of PSP during the follow-up. The recurrence rate in patients who underwent pleurectomy was significantly less than those who underwent pleural abrasion. Surgical procedure was the only factor affecting the recurrent attack of pneumothorax after surgery.
| Conclusion|| |
The patents who underwent pleural pleurectomy procedure had a greater blood loss than the group of patents who underwent pleural abrasion procedure. But the VATS pleurectomy technique proved to be more effective for the prevention of recurrent pneumothorax. Recurrent attacks of PSP were low in the pleurectomy group. Accordingly, VATS pleurectomy should be considered as the first choice for surgical intervention in the treatment of patients complaining of PSP.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]