Additional mechanical pleurodesis after thoracoscopic wedge resection and covering procedure for primary spontaneous pneumothorax

Abstract

Background Additional mechanical pleurodesis for the treatment of primary spontaneous pneumothorax (PSP) is believed to reduce the recurrence of PSP, and a covering procedure with absorbable mesh also shows comparable results. This study was conducted to determine whether additional mechanical pleurodesis would be effective in reducing recurrence after thoracoscopic wedge resection and covering procedure. Materials and methods Between May 2003 and August 2005, 99 patients underwent thoracoscopic bullectomy with staple line covering with absorbable cellulose mesh and fibrin glue followed by an additional mechanical pleurodesis. These patients were compared with 98 patients who underwent thoracoscopic bullectomy with staple line coverage alone. Results The additional mechanical pleurodesis group had findings comparable to those of the coverage group for duration of postoperative chest drainage, length of hospital stay, and complication rate. After median follow-up of 29.2 months, postoperative recurrence occurred in four patients (4.0%). Conclusions Additional mechanical pleurodesis after covering procedure is also effective in decreasing postoperative recurrence of PSP.Keywords Primary spontaneous pneumothorax (PSP) Á Mechanical pleurodesis Á Video-assisted thoracic surgery (VATS) Primary spontaneous pneumothorax (PSP) is well known to have high recurrence rates if not treated appropriately. There are ongoing debates on how to most effectively lower its recurrence after the first clinical treatment. Conservative treatments, such as needle aspiration or pleural drainage with a chest tube, show rather high recurrence rates, varying from 11% up to 36% [1]. Active surgical operations using thoracoscopy have resulted in a significant reduction in overall morbidity. However, wedge resection alone by video-assisted thoracoscopic surgery (VATS) has caused some doubts due to the high recurrence rates, hence various pleural symphyses have been performed in order to reduce its recurrence rate. In a previous retrospective study, Sakamoto et al. found that a staple line coverage procedure, which helps reduce the recurrence rate by minimizing the formation of new blebs near the staple line, showed a recurrence rate comparable to that of pleural symphysis, and as a result it has been confirmed that this procedure is effective in decreasing the recurrence rate of PSP [2,3].In this context, some questions have been raised as to whether additional mechanical pleurodesis can further reduce the recurrence rate if performed simultaneously

Preventing recurrence of spontaneous pneumothorax after thoracoscopic surgery: A review of recent results

“…These procedures can be broadly classifi ed into those targeting the site of the bullectomy and those targeting the parietal pleura. The additional procedures targeting the site of bullectomy include the application of fl eece-coated glue, 6 the attachment of an absorbent sheet, 13,16 and the spraying of a fi brin glue solution. 6 On the other hand, the additional procedures targeting the parietal pleura include mechanical abrasion of the parietal pleura, 18,21 excision of the pleura corresponding to the pulmonary apical portion, 1,8 chemical pleural adhesions using minomycin 12 and talc, 17 and further ablation of the parietal pleura using a laser 14 or argon beam.…”

“…5,6,11,16 The major causal factor of this high recurrence rate is new bulla formation which, according to many reports, occurs mainly near the staple lines. 6,13,16 Therefore, it is now suggested that additional surgical procedures and remedial measures, other than bullectomy with a stapler, are necessary to ensure a low recurrence rate.…”

“…The results for each additional surgical procedure are summarized in Table 4. 1,2,6,7,[12][13][14][15][16][17][18] Suturing/Loop Ligation Some reports advocated thoracoscopic suturing 4,19 or loop ligation 20,21 as opposed to stapled bullectomy, based on the rates of postoperative SP recurrence and cost. Suturing was superior to stapled bullectomy with respect to cost and a low recurrence rate.…”

“…One method described attaching an absorbent sheet 13,16 to the stapler-resected site. In many cases, this procedure involves the use of autologous blood and biological glue to place the absorbable sheet.…”

“…[1][2][3]5,[7][8][9][10]11 Subsequently, other thoracoscopic surgical procedures, in addition to stapled bullectomy only, were developed and the postoperative recurrence rate gradually declined. 6,[12][13][14][15][16] Now, the postoperative recurrence rate of SP is equal to or lower than that after thoracotomy. We review the recent published reports on the recurrence of SP after thoracoscopic surgery.…”