Results of repeated video-assisted thoracic surgery for recurrent pneumothorax after primary spontaneous pneumothorax

Results of repeated video-assisted thoracic surgery for recurrent pneumothorax after primary... Abstract OBJECTIVES This study aimed to identify the causes of recurrent pneumothorax and to evaluate the results of repeated video-assisted thoracic surgery (VATS) for recurrent pneumothorax after VATS wedge resection for primary spontaneous pneumothorax (PSP). METHODS A retrospective review was conducted on 188 patients with recurrent PSP, of a population of 1414 patients who underwent VATS wedge resection for PSP. Reoperations were performed when an air leak persisted longer than 3 days after closed thoracostomy, when a visible bulla of greater than 1 cm on high-resolution computed tomography (HRCT) was observed and when rerecurrence took place after other treatments. The HRCT findings before and after recurrence were compared to evaluate the type of the new bulla. Patients were divided into 2 groups according to the additional procedure performed during the first operation; in Group I, a coverage procedure was performed, and in Group II, mechanical pleurodesis was performed after VATS wedge resection. RESULTS During a median follow-up period of 27.7 months, 76 patients underwent repeated VATS for ipsilateral recurrent PSP after VATS. The indications for repeated VATS were the presence of a bulla on HRCT in 41 patients and a persistent air leak in 35 patients. Group I comprised 36 patients and Group II comprised 40 patients. The HRCT findings showed no bulla in 3 (4%) patients, were suspicious for a bulla in 11 (15%) patients, showed a bulla at the staple line in 26 (34%) patients and showed a new bulla in a location other than on the staple line in 36 (47%) patients. The frequency of new bullae was not different between the 2 groups, but Group I showed a lesser tendency for bullae to occur at the staple line than Group II. Dense fibrosis around the staple line was also found intraoperatively. CONCLUSIONS Repeated VATS was a feasible method to treat recurrent PSP after VATS for PSP. Pneumothorax, Thoracoscopy/video-assisted thoracic surgery, Reoperation, Pleurodesis, Recurrence INTRODUCTION Primary spontaneous pneumothorax (PSP) is a relatively common disease in young men and could cause psychological stress due to the fear of recurrence. With advances in video-assisted thoracoscopic surgery (VATS), surgical management of PSP by VATS is widely accepted as a treatment option, and its surgical indications continue to expand. Unfortunately, while the recurrence rate has been reported to be less than 3% after open thoracotomy, the recurrence rate after VATS wedge resection for PSP ranges from 3% to 7%, which is not as low as was expected when this technique was introduced [1–3]. However, just because the recurrence rate after VATS is higher than that after open thoracotomy does not necessarily mean that open thoracotomy is a more favourable treatment option. Instead, to reduce the recurrence after VATS, a range of additional procedures should be performed, such as mechanical or chemical pleurodesis or coverage procedures [4–7]. The causes of recurrent pneumothorax after surgical treatment include missed bullae, regeneration of bullae at the staple line and the formation of new bullae at locations other than the staple line [8]. To determine the cause of recurrence after VATS, it is necessary to compare high-resolution computed tomography (HRCT) results before and after recurrence and to analyse the intraoperative findings of the reoperation. Generally, observation, pleural drainage using a large or small calibre chest tube and a reoperation are considered to be the treatment options for recurrent PSP after VATS. However, no clear guideline or consensus has emerged on the treatment for recurrent PSP after VATS. Most surgeons are reluctant to choose reoperation for recurrent PSP, because reoperation is thought to be sometimes difficult to perform using VATS. Moreover, few studies have reported the causes of recurrence of PSP and the intraoperative findings of repeated VATS or analysed the feasibility of repeated VATS for recurrent PSP. Therefore, this study aimed to evaluate the causes of recurrence and the results of repeated VATS for recurrent PSP after VATS wedge resection. MATERIALS AND METHODS Korean Pneumothorax Study Group To clarify whether an additional coverage procedure on the staple line after VATS wedge resection for PSP prevents postoperative recurrence compared with additional mechanical pleurodesis, the Korean Pneumothorax Study Group (KPSG) performed a Phase III study of a multicentre prospective randomized controlled trial and enrolled 1414 patients from October 2006 [9]. Study population Of the 1414 patients enrolled in the KPSG cohort, 188 (8%) patients experienced ipsilateral recurrent PSP after VATS. After the exclusion of 112 (60%) patients who were treated by non-surgical methods, 60 patients who were treated by conservative observation and 52 patients who were treated by closed thoracostomy, 76 (40%) patients who underwent repeated VATS for recurrent PSP were included in this study. This study was conducted after permission was obtained from the institutional review board. Surgical procedure of first video-assisted thoracoscopic surgery in the Korean Pneumothorax Study Group We used the 3-port technique of Cho et al. [6]. After a thorough examination of the entire visceral pleural surface, bullae were resected using an endoscopic stapling device (Autosuture GIA Universal; Covidien, Mansfield, MA, USA or Echelon 60; Ethicon, Cincinnati, OH, USA) according to the surgeon’s preference. For the coverage group, inflated lungs around the staple line were covered with absorbable cellulose mesh (Surgicel; Ethicon), and then fibrin glue (TISSEEL; Baxter, Deerfield, IL, USA, Beriplast; CSL Boehring, Marburg, Germany or Greenplast; Green Cross Corp, Yongin, Korea) was sprayed on the mesh. For the pleurodesis group, mechanical pleurodesis was performed by scrubbing the parietal pleura with sandpaper and gauze until uniform blood oozing from the pleura was confirmed from the apex down to the fifth intercostal space. Protocol for managing recurrent primary spontaneous pneumothorax after video-assisted thoracoscopic surgery The light index was used to calculate the size of pneumothorax from the chest X-rays. In this formula, the percentage of pneumothorax equals 100 − (the diameter of the collapsed lung cubed divided by the diameter of the hemithorax cubed × 100). Pneumothorax with lung collapse of less than 20% was managed with conservative observation only. Closed thoracostomy was performed in patients with lung collapse greater than 20%. Reoperations were performed when an air leak persisted for longer than 3 days after closed thoracostomy, when a visible bulla of greater than 1 cm on HRCT was observed and when rerecurrence took place after other treatments. Grouping The patients who underwent repeated VATS for recurrent PSP were stratified into 2 groups according to the additional procedure performed at the first operation. Group I included those who underwent coverage and Group II underwent mechanical pleurodesis. Surgical procedure of repeated video-assisted thoracoscopic surgery The repeated VATS procedure was nearly the same as that of the first VATS procedure. The previous incisions were reopened, and additional ports were needed in some cases. After a review of the postero-anterior chest X-rays and HRCT at the time of recurrence, the first port was placed in a location with no adhesion. Adhesiolysis was performed meticulously, and extrapleural dissection was performed in some cases with severe adhesion. Wedge resection for bullae was done with an endoscopic stapling device. As an additional procedure, mechanical pleurodesis or a coverage procedure was carried out, according to the surgeon’s preference. Follow-up After being discharged from the hospital, patients visited an outpatient clinic a week after the discharge for follow-up care and continued the visits at 6-month intervals for 12 months. A chest X-ray was taken at each visit. Patients were instructed to visit a clinic or an emergency room if they had any symptoms related to the recurrence of pneumothorax such as chest pain, cough or dyspnoea. Statistical analysis Continuous variables were expressed as means ± standard deviations and analysed using the 2-sample t-test. Categorical variables were expressed as frequencies and analysed using the χ2 test. A 2-sided P-value of <0.05 was considered statistically significant. All analyses were performed using IBM SPSS 20.0 (IBM Corp., Armonk, NY, USA). RESULTS Patients During a median follow-up period of 27.7 months (range 11.1–66.7 months) after the first VATS procedure, 76 patients underwent repeated VATS for ipsilateral recurrent PSP. The mean age was 18.5 years (range 15–35 years), and 70 patients (92%) were male. Thirty-two (42%) patients experienced right-sided recurrent pneumothorax, whereas 44 (58%) patients experienced it in their left lung. The additional procedures performed after the first VATS wedge resection included a coverage procedure (Group I) in 36 (47%) patients and mechanical pleurodesis (Group II) in 40 (53%) patients. Recurrence after the first video-assisted thoracoscopic surgery wedge resection The mean time interval between the first VATS procedure and the first recurrence was 9.5 ± 9.4 months. The mean amount of pneumothorax was 35.5% ± 21.7% (range 2–90%). HRCT was performed in all patients and showed no bulla in 3 (4%) patients, was suspicious for a bulla in 11 (15%) patients, showed a bulla at the staple line (Fig. 1A) in 26 (34%) patients and showed a new bulla in a location other than the staple line (Fig. 1B) in 36 (47%) patients. No statistically significant difference was found between Groups I and II in terms of gender, age, the side of pneumothorax, the mean time interval before recurrence and the amount of pneumothorax (Table 1). On HRCT findings, the frequency of new bullae was not different between the 2 groups, although Group I showed a lesser tendency for bullae occurrence at the staple line than Group II (31% vs. 38%). Table 1: Comparison of characteristics between patients who underwent a coverage procedure (Group I) and those who underwent mechanical pleurodesis (Group II)   Group I  Group II  P-value  Number of patients  36  40    Gender: male, n (%)  34 (94.4)  36 (90.0)  0.473  Age (years), mean  18.9  17.9  0.203  Side of pneumothorax, n (%)      0.590   Right  14 (38.9)  18 (45.0)     Left  22 (61.1)  22 (55.0)    Amount of pneumothorax (%), mean  36.1  29.4  0.182  Time interval (months)a, mean  9.3  9.6  0.895  Bulla on HRCT, n (%)      0.786   No bulla  1 (2.8)  2 (5.0)     Suspicious  7 (19.4)  4 (10.0)     Bulla at the staple line  11 (30.6)  15 (37.5)     New bulla  17 (47.2)  19 (47.5)      Group I  Group II  P-value  Number of patients  36  40    Gender: male, n (%)  34 (94.4)  36 (90.0)  0.473  Age (years), mean  18.9  17.9  0.203  Side of pneumothorax, n (%)      0.590   Right  14 (38.9)  18 (45.0)     Left  22 (61.1)  22 (55.0)    Amount of pneumothorax (%), mean  36.1  29.4  0.182  Time interval (months)a, mean  9.3  9.6  0.895  Bulla on HRCT, n (%)      0.786   No bulla  1 (2.8)  2 (5.0)     Suspicious  7 (19.4)  4 (10.0)     Bulla at the staple line  11 (30.6)  15 (37.5)     New bulla  17 (47.2)  19 (47.5)    a Time interval: from first operation to recurrence. HRCT: high-resolution computed tomography. Figure 1: View largeDownload slide (A) Bulla at the stapled line; new bulla was formed at stapled line. (B) New bulla; new bulla was formed at different location other than previous resected line. Figure 1: View largeDownload slide (A) Bulla at the stapled line; new bulla was formed at stapled line. (B) New bulla; new bulla was formed at different location other than previous resected line. Indications of repeated video-assisted thoracoscopic surgery wedge resection Of those who were managed with observation as the initial treatment, 15 patients underwent a reoperation due to a bulla on HRCT. Among those who were managed with closed thoracostomy, 61 patients eventually underwent reoperations due to a persistent air leak in 35 cases and due to a bulla on HRCT in 26 cases. Overall, the indications of repeated VATS were the presence of a bulla on HRCT in 41 (54%) patients and persistent air leak in 35 (46%) patients. There was no significant difference in the indications between the 2 groups (P = 0.247). Intraoperative findings of reoperation The degree of adhesion was observed intraoperatively; there were no adhesions observed in 22 (29%) patients in Group I, focal adhesions around the staple line in 28 (37%) patients (Fig. 2A), diffuse adhesions from the apex to the fifth intercostal space in 19 (25%) patients (Fig. 2B) and diffuse adhesions below the fifth intercostal space in 7 (9%) patients. Dense fibrosis and several bullae around the staple line were also found intraoperatively in patients who underwent a coverage procedure (Fig. 2C). After dissection, no bulla was found in 7 (9%) patients, a newly developed bulla in a location other than the staple line in 19 (25%) patients, a bulla on the staple line (Fig. 3) in 42 (55%) patients and both in 8 (11%) patients. The incidence of new bulla formation was not different between the 2 groups; however, the incidence of bullae at the staple line was higher in Group II (Table 2). Table 2: Comparison of operative findings between patients who underwent a coverage procedure (Group I) and those who underwent mechanical pleurodesis (Group II)   Group I  Group II  P-value  Indications, n (%)      0.247   Visible bulla on HRCT  21 (58.3)  20 (50.0)     Air leak for more than 3 days  15 (41.7)  20 (50.0)    Intraoperative bulla, n (%)      0.737   No bulla  3 (8.3)  4 (10.0)     New bulla  11 (30.6)  8 (20.0)     Bulla on the staple line  18 (50.0)  24 (60.0)     Mixed  4 (11.1)  4 (10.0)    Complications, n (%)  5 (13.9)  5 (12.5)  0.858  Duration of chest tube (days), mean  2.4  2.8  0.363  Duration of hospitalization (days), mean  3.4  3.8  0.337    Group I  Group II  P-value  Indications, n (%)      0.247   Visible bulla on HRCT  21 (58.3)  20 (50.0)     Air leak for more than 3 days  15 (41.7)  20 (50.0)    Intraoperative bulla, n (%)      0.737   No bulla  3 (8.3)  4 (10.0)     New bulla  11 (30.6)  8 (20.0)     Bulla on the staple line  18 (50.0)  24 (60.0)     Mixed  4 (11.1)  4 (10.0)    Complications, n (%)  5 (13.9)  5 (12.5)  0.858  Duration of chest tube (days), mean  2.4  2.8  0.363  Duration of hospitalization (days), mean  3.4  3.8  0.337  HRCT, high-resolution computed tomography. Figure 2: View largeDownload slide (A) Focal adhesion around stapled line. (B) Diffuse adhesion from apex to fifth intercostal space. (C) Dense fibrosis and several bulla around the stapled line. Figure 2: View largeDownload slide (A) Focal adhesion around stapled line. (B) Diffuse adhesion from apex to fifth intercostal space. (C) Dense fibrosis and several bulla around the stapled line. Figure 3: View largeDownload slide Bulla on intraoperative findings on the stapled line. Figure 3: View largeDownload slide Bulla on intraoperative findings on the stapled line. Postoperative course The mean durations of chest tube drainage and hospital stay after the reoperation were 2.6 and 3.6 days, respectively. Postoperative complications occurred in 10 (13%) patients, including a non-fully expanded lung in 7 patients, air leak longer than 5 days in 4 patients and wound infection in 1 patient. No significant difference was found between the 2 groups. After repeated VATS, rerecurrence was observed in 2 (3%) patients. Re-recurrence rate according to the management method Of the recurrent cases, 60 were treated by observation, 52 by closed thoracostomy and 76 by reoperation. Repeated recurrence was seen in 12 of the 60 (20%) cases in the observation group, 17 of the 52 (33%) cases in the closed thoracostomy group and 2 of the 76 (3%) cases in the reoperation group. DISCUSSION Based on the results of repeated VATS, we can observe that the most common reason for recurrent PSP after VATS was the formation of a bulla on the previous staple line, followed by the new bulla formation in a location other than the staple line. The overall recurrence rate after VATS treatment for PSP has been reported to be around 4% in the literature, which is much lower than the rate of 8% reported in the KPSG series [9]. For the treatment of recurrent PSP, conservative observation was performed in 32% of patients in this study, closed thoracostomy in 28% and reoperation in 40%. After the first treatment of recurrent PSP, repeated recurrence was seen in 20% of patients in the observation group, 33% in the closed thoracostomy group and only 3% in the reoperation group. Few studies have investigated the management methods for recurrent PSP after VATS or compared the effects of various treatment methods. Chen et al. [10] reported that the re-recurrence rate was 63.1% after observation, 7.1% after closed thoracostomy and 0% after reoperation and concluded that both observation and closed thoracostomy should not be recommended due to their high treatment failure rates. The reasons for recurrence after VATS are known to include the development of a new bulla that did not exist before the first VATS procedure, the formation of a new bulla at the previous staple line and a missed bulla. In this study, based on a comparison of HRCT findings before the first VATS procedure with the HRCT findings at the time of recurrence after VATS, no missed bullae were found. No statistically significant difference between the 2 groups was found according to the type of bulla in this study. New bulla formation in a location other than the staple line was seen on HRCT in 36 patients, and this might be common in younger patients. As patients continue growing taller, a new bulla appears at the apex, just as the first pneumothorax. However, the mechanism of bulla formation at the previous staple line is different from that of new bulla formation. The mechanism through which a bulla is generated at the resected margin is attributed to the presence of tension at the staple line. Tsuboshima et al. [11] reported a bulla at the resected margin in 37.1% of cases in 1-year postoperative HRCT findings and concluded that a resected lung weight greater than 1.5 g was a significant risk factor for a bulla at the resected margin. In our study, large bullae were commonly seen in patients with recurrence, in whom the time interval from the first VATS procedure to recurrence was relatively short. This observation suggests that bullae at the staple line form more easily and grow more quickly than bullae at other lung surfaces. Preoperative HRCT and intraoperative findings did not significantly differ in terms of the bullae that were the cause of recurrence; however, it is not easy to intraoperatively distinguish a bulla that has been regenerated at the staple line and a new bulla adjacent to the staple line after dissection. The main concern for repeated VATS is the possibility of complications caused by severe pleural symphysis after the first operation. With a history of mechanical pleurodesis such as pleurectomy, abrasion of the pleura or a history of chemical pleurodesis from the first operation, it is hard to perform a reoperation via VATS, and complications of reoperation, such as bleeding, a longer period of chest tube drainage or a longer hospital stay, are highly likely to occur. Doddoli et al. [12] reported a 31% conversion rate after prior talc pleurodesis and explained that the main cause of this was the presence of dense pleural adhesions at the mediastinal part of the pleural cavity. They also revealed that the postoperative complication rate after VATS for recurrent pneumothorax following talc pleurodesis reached 22%. However, Cardillo et al. [13] reported that repeated VATS was performed in 70.4% of patients with recurrent pneumothorax, even after a 5.2% conversion rate from VATS to thoracotomy and concluded that repeated VATS is a promising tool for surgical therapy for recurrent pneumothorax following VATS and pleurectomy. In terms of repeated VATS for recurrent pneumothorax, the rate of repeated VATS in our study might be considered high. There were no cases of conversion to open thoracotomy. The first reason for active attempts at repeated VATS was that not all enrolled patients received chemical pleurodesis and 36 patients in this study did not receive any kind of pleurodesis. Although some patients received mechanical pleurodesis, it was mostly limited to the apex regions, which resulted in a very low rate of dense adhesions. The second reason was rechecking HRCT after recurrence. Doing so was very helpful in identifying the degree of adhesion and the presence of bullae. Using HRCT as a guide can eliminate the incidence of lung injury or bleeding from blunt dissection. In our study, postoperative complications developed in only 10 patients. Most of them were minor problems, such as pleural detachment and persistent air leak for more than 5 days. The mean duration of chest tube and hospitalization was relatively short. Therefore, repeated VATS wedge resection for recurrent PSP after surgical management is feasible, especially in patients who have not undergone chemical pleurodesis. Conflict of interest: none declared. REFERENCES 1 Chan P, Clarke P, Daniel FJ, Knight SR, Seevanayagam S. Efficacy study of video-assisted thoracoscopic surgery pleurodesis for spontaneous pneumothorax. Ann Thorac Surg  2001; 71: 452– 4. Google Scholar CrossRef Search ADS PubMed  2 Hatz RA, Kaps MF, Meimarakis G, Loehe F, Muller C, Furst H. Long-term results after video-assisted thoracoscopic surgery for first-time and recurrent spontaneous pneumothorax. Ann Thorac Surg  2000; 70: 253– 7. Google Scholar CrossRef Search ADS PubMed  3 Rena O, Massera F, Papalia E, Della Pona C, Robustellini M, Casadio C. Surgical pleurodesis for Vanderschueren's stage III primary spontaneous pneumothorax. Eur Respir J  2008; 31: 837– 41. Google Scholar CrossRef Search ADS PubMed  4 Ayed AK, Al-Din HJ. The results of thoracoscopic surgery for primary spontaneous pneumothorax. Chest  2000; 118: 235– 8. Google Scholar CrossRef Search ADS PubMed  5 Chen JS, Hsu HH, Chen RJ, Kuo SW, Huang PM, Tsai PR et al.   Additional minocycline pleurodesis after thoracoscopic surgery for primary spontaneous pneumothorax. Am J Respir Crit Care Med  2006; 173: 548– 54. Google Scholar CrossRef Search ADS PubMed  6 Cho S, Huh DM, Kim BH, Lee S, Kwon OC, Ahn WS et al.   Staple line covering procedure after thoracoscopic bullectomy for the management of primary spontaneous pneumothorax. Thorac Cardiovasc Surg  2008; 56: 217– 20. Google Scholar CrossRef Search ADS PubMed  7 Cho S, Ryu KM, Jheon S, Sung SW, Kim BH, Huh DM. Additional mechanical pleurodesis after thoracoscopic wedge resection and covering procedure for primary spontaneous pneumothorax. Surg Endosc  2009; 23: 986– 90. Google Scholar CrossRef Search ADS PubMed  8 Sakamoto K, Kase M, Mo M, Kurata H, Nagatomo A, Kunikane H et al.   Regrowth of bullae around the staple-line is one of the causes of postoperative recurrence in thoracoscopic surgery for spontaneous pneumothorax. Kyobu Geka  1999; 52: 939– 42. Google Scholar PubMed  9 Lee S, Kim HR, Cho S, Huh DM, Lee EB, Ryu KM et al.   Staple line coverage after bullectomy for primary spontaneous pneumothorax: a randomized trial. Ann Thorac Surg  2014; 98: 2005– 11. Google Scholar CrossRef Search ADS PubMed  10 Chen JS, Hsu HH, Kuo SW, Huang PM, Lee JM, Lee YC. Management of recurrent primary spontaneous pneumothorax after thoracoscopic surgery: should observation, drainage, redo thoracoscopy, or thoracotomy be used? Surg Endosc  2009; 23: 2438– 44. Google Scholar CrossRef Search ADS PubMed  11 Tsuboshima K, Nagata M, Wakahara T, Matoba Y, Matsumoto S, Maniwa Y. Relationship between postoperative bulla neogenesis at the staple line and the resected lung volume in primary spontaneous pneumothorax. Gen Thorac Cardiovasc Surg  2015; 63: 572– 5. Google Scholar CrossRef Search ADS PubMed  12 Doddoli C, Barlesi F, Fraticelli A, Thomas P, Astoul P, Giudicelli R et al.   Video-assisted thoracoscopic management of recurrent primary spontaneous pneumothorax after prior talc pleurodesis: a feasible, safe and efficient treatment option. Eur J Cardiothorac Surg  2004; 26: 889– 92. Google Scholar CrossRef Search ADS PubMed  13 Cardillo G, Facciolo F, Regal M, Carbone L, Corzani F, Ricci A et al.   Recurrences following videothoracoscopic treatment of primary spontaneous pneumothorax: the role of redo-videothoracoscopy. Eur J Cardiothorac Surg  2001; 19: 396– 9. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Journal of Cardio-Thoracic Surgery Oxford University Press

Results of repeated video-assisted thoracic surgery for recurrent pneumothorax after primary spontaneous pneumothorax

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Abstract

Abstract OBJECTIVES This study aimed to identify the causes of recurrent pneumothorax and to evaluate the results of repeated video-assisted thoracic surgery (VATS) for recurrent pneumothorax after VATS wedge resection for primary spontaneous pneumothorax (PSP). METHODS A retrospective review was conducted on 188 patients with recurrent PSP, of a population of 1414 patients who underwent VATS wedge resection for PSP. Reoperations were performed when an air leak persisted longer than 3 days after closed thoracostomy, when a visible bulla of greater than 1 cm on high-resolution computed tomography (HRCT) was observed and when rerecurrence took place after other treatments. The HRCT findings before and after recurrence were compared to evaluate the type of the new bulla. Patients were divided into 2 groups according to the additional procedure performed during the first operation; in Group I, a coverage procedure was performed, and in Group II, mechanical pleurodesis was performed after VATS wedge resection. RESULTS During a median follow-up period of 27.7 months, 76 patients underwent repeated VATS for ipsilateral recurrent PSP after VATS. The indications for repeated VATS were the presence of a bulla on HRCT in 41 patients and a persistent air leak in 35 patients. Group I comprised 36 patients and Group II comprised 40 patients. The HRCT findings showed no bulla in 3 (4%) patients, were suspicious for a bulla in 11 (15%) patients, showed a bulla at the staple line in 26 (34%) patients and showed a new bulla in a location other than on the staple line in 36 (47%) patients. The frequency of new bullae was not different between the 2 groups, but Group I showed a lesser tendency for bullae to occur at the staple line than Group II. Dense fibrosis around the staple line was also found intraoperatively. CONCLUSIONS Repeated VATS was a feasible method to treat recurrent PSP after VATS for PSP. Pneumothorax, Thoracoscopy/video-assisted thoracic surgery, Reoperation, Pleurodesis, Recurrence INTRODUCTION Primary spontaneous pneumothorax (PSP) is a relatively common disease in young men and could cause psychological stress due to the fear of recurrence. With advances in video-assisted thoracoscopic surgery (VATS), surgical management of PSP by VATS is widely accepted as a treatment option, and its surgical indications continue to expand. Unfortunately, while the recurrence rate has been reported to be less than 3% after open thoracotomy, the recurrence rate after VATS wedge resection for PSP ranges from 3% to 7%, which is not as low as was expected when this technique was introduced [1–3]. However, just because the recurrence rate after VATS is higher than that after open thoracotomy does not necessarily mean that open thoracotomy is a more favourable treatment option. Instead, to reduce the recurrence after VATS, a range of additional procedures should be performed, such as mechanical or chemical pleurodesis or coverage procedures [4–7]. The causes of recurrent pneumothorax after surgical treatment include missed bullae, regeneration of bullae at the staple line and the formation of new bullae at locations other than the staple line [8]. To determine the cause of recurrence after VATS, it is necessary to compare high-resolution computed tomography (HRCT) results before and after recurrence and to analyse the intraoperative findings of the reoperation. Generally, observation, pleural drainage using a large or small calibre chest tube and a reoperation are considered to be the treatment options for recurrent PSP after VATS. However, no clear guideline or consensus has emerged on the treatment for recurrent PSP after VATS. Most surgeons are reluctant to choose reoperation for recurrent PSP, because reoperation is thought to be sometimes difficult to perform using VATS. Moreover, few studies have reported the causes of recurrence of PSP and the intraoperative findings of repeated VATS or analysed the feasibility of repeated VATS for recurrent PSP. Therefore, this study aimed to evaluate the causes of recurrence and the results of repeated VATS for recurrent PSP after VATS wedge resection. MATERIALS AND METHODS Korean Pneumothorax Study Group To clarify whether an additional coverage procedure on the staple line after VATS wedge resection for PSP prevents postoperative recurrence compared with additional mechanical pleurodesis, the Korean Pneumothorax Study Group (KPSG) performed a Phase III study of a multicentre prospective randomized controlled trial and enrolled 1414 patients from October 2006 [9]. Study population Of the 1414 patients enrolled in the KPSG cohort, 188 (8%) patients experienced ipsilateral recurrent PSP after VATS. After the exclusion of 112 (60%) patients who were treated by non-surgical methods, 60 patients who were treated by conservative observation and 52 patients who were treated by closed thoracostomy, 76 (40%) patients who underwent repeated VATS for recurrent PSP were included in this study. This study was conducted after permission was obtained from the institutional review board. Surgical procedure of first video-assisted thoracoscopic surgery in the Korean Pneumothorax Study Group We used the 3-port technique of Cho et al. [6]. After a thorough examination of the entire visceral pleural surface, bullae were resected using an endoscopic stapling device (Autosuture GIA Universal; Covidien, Mansfield, MA, USA or Echelon 60; Ethicon, Cincinnati, OH, USA) according to the surgeon’s preference. For the coverage group, inflated lungs around the staple line were covered with absorbable cellulose mesh (Surgicel; Ethicon), and then fibrin glue (TISSEEL; Baxter, Deerfield, IL, USA, Beriplast; CSL Boehring, Marburg, Germany or Greenplast; Green Cross Corp, Yongin, Korea) was sprayed on the mesh. For the pleurodesis group, mechanical pleurodesis was performed by scrubbing the parietal pleura with sandpaper and gauze until uniform blood oozing from the pleura was confirmed from the apex down to the fifth intercostal space. Protocol for managing recurrent primary spontaneous pneumothorax after video-assisted thoracoscopic surgery The light index was used to calculate the size of pneumothorax from the chest X-rays. In this formula, the percentage of pneumothorax equals 100 − (the diameter of the collapsed lung cubed divided by the diameter of the hemithorax cubed × 100). Pneumothorax with lung collapse of less than 20% was managed with conservative observation only. Closed thoracostomy was performed in patients with lung collapse greater than 20%. Reoperations were performed when an air leak persisted for longer than 3 days after closed thoracostomy, when a visible bulla of greater than 1 cm on HRCT was observed and when rerecurrence took place after other treatments. Grouping The patients who underwent repeated VATS for recurrent PSP were stratified into 2 groups according to the additional procedure performed at the first operation. Group I included those who underwent coverage and Group II underwent mechanical pleurodesis. Surgical procedure of repeated video-assisted thoracoscopic surgery The repeated VATS procedure was nearly the same as that of the first VATS procedure. The previous incisions were reopened, and additional ports were needed in some cases. After a review of the postero-anterior chest X-rays and HRCT at the time of recurrence, the first port was placed in a location with no adhesion. Adhesiolysis was performed meticulously, and extrapleural dissection was performed in some cases with severe adhesion. Wedge resection for bullae was done with an endoscopic stapling device. As an additional procedure, mechanical pleurodesis or a coverage procedure was carried out, according to the surgeon’s preference. Follow-up After being discharged from the hospital, patients visited an outpatient clinic a week after the discharge for follow-up care and continued the visits at 6-month intervals for 12 months. A chest X-ray was taken at each visit. Patients were instructed to visit a clinic or an emergency room if they had any symptoms related to the recurrence of pneumothorax such as chest pain, cough or dyspnoea. Statistical analysis Continuous variables were expressed as means ± standard deviations and analysed using the 2-sample t-test. Categorical variables were expressed as frequencies and analysed using the χ2 test. A 2-sided P-value of <0.05 was considered statistically significant. All analyses were performed using IBM SPSS 20.0 (IBM Corp., Armonk, NY, USA). RESULTS Patients During a median follow-up period of 27.7 months (range 11.1–66.7 months) after the first VATS procedure, 76 patients underwent repeated VATS for ipsilateral recurrent PSP. The mean age was 18.5 years (range 15–35 years), and 70 patients (92%) were male. Thirty-two (42%) patients experienced right-sided recurrent pneumothorax, whereas 44 (58%) patients experienced it in their left lung. The additional procedures performed after the first VATS wedge resection included a coverage procedure (Group I) in 36 (47%) patients and mechanical pleurodesis (Group II) in 40 (53%) patients. Recurrence after the first video-assisted thoracoscopic surgery wedge resection The mean time interval between the first VATS procedure and the first recurrence was 9.5 ± 9.4 months. The mean amount of pneumothorax was 35.5% ± 21.7% (range 2–90%). HRCT was performed in all patients and showed no bulla in 3 (4%) patients, was suspicious for a bulla in 11 (15%) patients, showed a bulla at the staple line (Fig. 1A) in 26 (34%) patients and showed a new bulla in a location other than the staple line (Fig. 1B) in 36 (47%) patients. No statistically significant difference was found between Groups I and II in terms of gender, age, the side of pneumothorax, the mean time interval before recurrence and the amount of pneumothorax (Table 1). On HRCT findings, the frequency of new bullae was not different between the 2 groups, although Group I showed a lesser tendency for bullae occurrence at the staple line than Group II (31% vs. 38%). Table 1: Comparison of characteristics between patients who underwent a coverage procedure (Group I) and those who underwent mechanical pleurodesis (Group II)   Group I  Group II  P-value  Number of patients  36  40    Gender: male, n (%)  34 (94.4)  36 (90.0)  0.473  Age (years), mean  18.9  17.9  0.203  Side of pneumothorax, n (%)      0.590   Right  14 (38.9)  18 (45.0)     Left  22 (61.1)  22 (55.0)    Amount of pneumothorax (%), mean  36.1  29.4  0.182  Time interval (months)a, mean  9.3  9.6  0.895  Bulla on HRCT, n (%)      0.786   No bulla  1 (2.8)  2 (5.0)     Suspicious  7 (19.4)  4 (10.0)     Bulla at the staple line  11 (30.6)  15 (37.5)     New bulla  17 (47.2)  19 (47.5)      Group I  Group II  P-value  Number of patients  36  40    Gender: male, n (%)  34 (94.4)  36 (90.0)  0.473  Age (years), mean  18.9  17.9  0.203  Side of pneumothorax, n (%)      0.590   Right  14 (38.9)  18 (45.0)     Left  22 (61.1)  22 (55.0)    Amount of pneumothorax (%), mean  36.1  29.4  0.182  Time interval (months)a, mean  9.3  9.6  0.895  Bulla on HRCT, n (%)      0.786   No bulla  1 (2.8)  2 (5.0)     Suspicious  7 (19.4)  4 (10.0)     Bulla at the staple line  11 (30.6)  15 (37.5)     New bulla  17 (47.2)  19 (47.5)    a Time interval: from first operation to recurrence. HRCT: high-resolution computed tomography. Figure 1: View largeDownload slide (A) Bulla at the stapled line; new bulla was formed at stapled line. (B) New bulla; new bulla was formed at different location other than previous resected line. Figure 1: View largeDownload slide (A) Bulla at the stapled line; new bulla was formed at stapled line. (B) New bulla; new bulla was formed at different location other than previous resected line. Indications of repeated video-assisted thoracoscopic surgery wedge resection Of those who were managed with observation as the initial treatment, 15 patients underwent a reoperation due to a bulla on HRCT. Among those who were managed with closed thoracostomy, 61 patients eventually underwent reoperations due to a persistent air leak in 35 cases and due to a bulla on HRCT in 26 cases. Overall, the indications of repeated VATS were the presence of a bulla on HRCT in 41 (54%) patients and persistent air leak in 35 (46%) patients. There was no significant difference in the indications between the 2 groups (P = 0.247). Intraoperative findings of reoperation The degree of adhesion was observed intraoperatively; there were no adhesions observed in 22 (29%) patients in Group I, focal adhesions around the staple line in 28 (37%) patients (Fig. 2A), diffuse adhesions from the apex to the fifth intercostal space in 19 (25%) patients (Fig. 2B) and diffuse adhesions below the fifth intercostal space in 7 (9%) patients. Dense fibrosis and several bullae around the staple line were also found intraoperatively in patients who underwent a coverage procedure (Fig. 2C). After dissection, no bulla was found in 7 (9%) patients, a newly developed bulla in a location other than the staple line in 19 (25%) patients, a bulla on the staple line (Fig. 3) in 42 (55%) patients and both in 8 (11%) patients. The incidence of new bulla formation was not different between the 2 groups; however, the incidence of bullae at the staple line was higher in Group II (Table 2). Table 2: Comparison of operative findings between patients who underwent a coverage procedure (Group I) and those who underwent mechanical pleurodesis (Group II)   Group I  Group II  P-value  Indications, n (%)      0.247   Visible bulla on HRCT  21 (58.3)  20 (50.0)     Air leak for more than 3 days  15 (41.7)  20 (50.0)    Intraoperative bulla, n (%)      0.737   No bulla  3 (8.3)  4 (10.0)     New bulla  11 (30.6)  8 (20.0)     Bulla on the staple line  18 (50.0)  24 (60.0)     Mixed  4 (11.1)  4 (10.0)    Complications, n (%)  5 (13.9)  5 (12.5)  0.858  Duration of chest tube (days), mean  2.4  2.8  0.363  Duration of hospitalization (days), mean  3.4  3.8  0.337    Group I  Group II  P-value  Indications, n (%)      0.247   Visible bulla on HRCT  21 (58.3)  20 (50.0)     Air leak for more than 3 days  15 (41.7)  20 (50.0)    Intraoperative bulla, n (%)      0.737   No bulla  3 (8.3)  4 (10.0)     New bulla  11 (30.6)  8 (20.0)     Bulla on the staple line  18 (50.0)  24 (60.0)     Mixed  4 (11.1)  4 (10.0)    Complications, n (%)  5 (13.9)  5 (12.5)  0.858  Duration of chest tube (days), mean  2.4  2.8  0.363  Duration of hospitalization (days), mean  3.4  3.8  0.337  HRCT, high-resolution computed tomography. Figure 2: View largeDownload slide (A) Focal adhesion around stapled line. (B) Diffuse adhesion from apex to fifth intercostal space. (C) Dense fibrosis and several bulla around the stapled line. Figure 2: View largeDownload slide (A) Focal adhesion around stapled line. (B) Diffuse adhesion from apex to fifth intercostal space. (C) Dense fibrosis and several bulla around the stapled line. Figure 3: View largeDownload slide Bulla on intraoperative findings on the stapled line. Figure 3: View largeDownload slide Bulla on intraoperative findings on the stapled line. Postoperative course The mean durations of chest tube drainage and hospital stay after the reoperation were 2.6 and 3.6 days, respectively. Postoperative complications occurred in 10 (13%) patients, including a non-fully expanded lung in 7 patients, air leak longer than 5 days in 4 patients and wound infection in 1 patient. No significant difference was found between the 2 groups. After repeated VATS, rerecurrence was observed in 2 (3%) patients. Re-recurrence rate according to the management method Of the recurrent cases, 60 were treated by observation, 52 by closed thoracostomy and 76 by reoperation. Repeated recurrence was seen in 12 of the 60 (20%) cases in the observation group, 17 of the 52 (33%) cases in the closed thoracostomy group and 2 of the 76 (3%) cases in the reoperation group. DISCUSSION Based on the results of repeated VATS, we can observe that the most common reason for recurrent PSP after VATS was the formation of a bulla on the previous staple line, followed by the new bulla formation in a location other than the staple line. The overall recurrence rate after VATS treatment for PSP has been reported to be around 4% in the literature, which is much lower than the rate of 8% reported in the KPSG series [9]. For the treatment of recurrent PSP, conservative observation was performed in 32% of patients in this study, closed thoracostomy in 28% and reoperation in 40%. After the first treatment of recurrent PSP, repeated recurrence was seen in 20% of patients in the observation group, 33% in the closed thoracostomy group and only 3% in the reoperation group. Few studies have investigated the management methods for recurrent PSP after VATS or compared the effects of various treatment methods. Chen et al. [10] reported that the re-recurrence rate was 63.1% after observation, 7.1% after closed thoracostomy and 0% after reoperation and concluded that both observation and closed thoracostomy should not be recommended due to their high treatment failure rates. The reasons for recurrence after VATS are known to include the development of a new bulla that did not exist before the first VATS procedure, the formation of a new bulla at the previous staple line and a missed bulla. In this study, based on a comparison of HRCT findings before the first VATS procedure with the HRCT findings at the time of recurrence after VATS, no missed bullae were found. No statistically significant difference between the 2 groups was found according to the type of bulla in this study. New bulla formation in a location other than the staple line was seen on HRCT in 36 patients, and this might be common in younger patients. As patients continue growing taller, a new bulla appears at the apex, just as the first pneumothorax. However, the mechanism of bulla formation at the previous staple line is different from that of new bulla formation. The mechanism through which a bulla is generated at the resected margin is attributed to the presence of tension at the staple line. Tsuboshima et al. [11] reported a bulla at the resected margin in 37.1% of cases in 1-year postoperative HRCT findings and concluded that a resected lung weight greater than 1.5 g was a significant risk factor for a bulla at the resected margin. In our study, large bullae were commonly seen in patients with recurrence, in whom the time interval from the first VATS procedure to recurrence was relatively short. This observation suggests that bullae at the staple line form more easily and grow more quickly than bullae at other lung surfaces. Preoperative HRCT and intraoperative findings did not significantly differ in terms of the bullae that were the cause of recurrence; however, it is not easy to intraoperatively distinguish a bulla that has been regenerated at the staple line and a new bulla adjacent to the staple line after dissection. The main concern for repeated VATS is the possibility of complications caused by severe pleural symphysis after the first operation. With a history of mechanical pleurodesis such as pleurectomy, abrasion of the pleura or a history of chemical pleurodesis from the first operation, it is hard to perform a reoperation via VATS, and complications of reoperation, such as bleeding, a longer period of chest tube drainage or a longer hospital stay, are highly likely to occur. Doddoli et al. [12] reported a 31% conversion rate after prior talc pleurodesis and explained that the main cause of this was the presence of dense pleural adhesions at the mediastinal part of the pleural cavity. They also revealed that the postoperative complication rate after VATS for recurrent pneumothorax following talc pleurodesis reached 22%. However, Cardillo et al. [13] reported that repeated VATS was performed in 70.4% of patients with recurrent pneumothorax, even after a 5.2% conversion rate from VATS to thoracotomy and concluded that repeated VATS is a promising tool for surgical therapy for recurrent pneumothorax following VATS and pleurectomy. In terms of repeated VATS for recurrent pneumothorax, the rate of repeated VATS in our study might be considered high. There were no cases of conversion to open thoracotomy. The first reason for active attempts at repeated VATS was that not all enrolled patients received chemical pleurodesis and 36 patients in this study did not receive any kind of pleurodesis. Although some patients received mechanical pleurodesis, it was mostly limited to the apex regions, which resulted in a very low rate of dense adhesions. The second reason was rechecking HRCT after recurrence. Doing so was very helpful in identifying the degree of adhesion and the presence of bullae. Using HRCT as a guide can eliminate the incidence of lung injury or bleeding from blunt dissection. In our study, postoperative complications developed in only 10 patients. Most of them were minor problems, such as pleural detachment and persistent air leak for more than 5 days. The mean duration of chest tube and hospitalization was relatively short. Therefore, repeated VATS wedge resection for recurrent PSP after surgical management is feasible, especially in patients who have not undergone chemical pleurodesis. Conflict of interest: none declared. REFERENCES 1 Chan P, Clarke P, Daniel FJ, Knight SR, Seevanayagam S. Efficacy study of video-assisted thoracoscopic surgery pleurodesis for spontaneous pneumothorax. Ann Thorac Surg  2001; 71: 452– 4. Google Scholar CrossRef Search ADS PubMed  2 Hatz RA, Kaps MF, Meimarakis G, Loehe F, Muller C, Furst H. Long-term results after video-assisted thoracoscopic surgery for first-time and recurrent spontaneous pneumothorax. Ann Thorac Surg  2000; 70: 253– 7. Google Scholar CrossRef Search ADS PubMed  3 Rena O, Massera F, Papalia E, Della Pona C, Robustellini M, Casadio C. Surgical pleurodesis for Vanderschueren's stage III primary spontaneous pneumothorax. Eur Respir J  2008; 31: 837– 41. Google Scholar CrossRef Search ADS PubMed  4 Ayed AK, Al-Din HJ. The results of thoracoscopic surgery for primary spontaneous pneumothorax. Chest  2000; 118: 235– 8. Google Scholar CrossRef Search ADS PubMed  5 Chen JS, Hsu HH, Chen RJ, Kuo SW, Huang PM, Tsai PR et al.   Additional minocycline pleurodesis after thoracoscopic surgery for primary spontaneous pneumothorax. Am J Respir Crit Care Med  2006; 173: 548– 54. Google Scholar CrossRef Search ADS PubMed  6 Cho S, Huh DM, Kim BH, Lee S, Kwon OC, Ahn WS et al.   Staple line covering procedure after thoracoscopic bullectomy for the management of primary spontaneous pneumothorax. Thorac Cardiovasc Surg  2008; 56: 217– 20. Google Scholar CrossRef Search ADS PubMed  7 Cho S, Ryu KM, Jheon S, Sung SW, Kim BH, Huh DM. Additional mechanical pleurodesis after thoracoscopic wedge resection and covering procedure for primary spontaneous pneumothorax. Surg Endosc  2009; 23: 986– 90. Google Scholar CrossRef Search ADS PubMed  8 Sakamoto K, Kase M, Mo M, Kurata H, Nagatomo A, Kunikane H et al.   Regrowth of bullae around the staple-line is one of the causes of postoperative recurrence in thoracoscopic surgery for spontaneous pneumothorax. Kyobu Geka  1999; 52: 939– 42. Google Scholar PubMed  9 Lee S, Kim HR, Cho S, Huh DM, Lee EB, Ryu KM et al.   Staple line coverage after bullectomy for primary spontaneous pneumothorax: a randomized trial. Ann Thorac Surg  2014; 98: 2005– 11. Google Scholar CrossRef Search ADS PubMed  10 Chen JS, Hsu HH, Kuo SW, Huang PM, Lee JM, Lee YC. Management of recurrent primary spontaneous pneumothorax after thoracoscopic surgery: should observation, drainage, redo thoracoscopy, or thoracotomy be used? Surg Endosc  2009; 23: 2438– 44. Google Scholar CrossRef Search ADS PubMed  11 Tsuboshima K, Nagata M, Wakahara T, Matoba Y, Matsumoto S, Maniwa Y. Relationship between postoperative bulla neogenesis at the staple line and the resected lung volume in primary spontaneous pneumothorax. Gen Thorac Cardiovasc Surg  2015; 63: 572– 5. Google Scholar CrossRef Search ADS PubMed  12 Doddoli C, Barlesi F, Fraticelli A, Thomas P, Astoul P, Giudicelli R et al.   Video-assisted thoracoscopic management of recurrent primary spontaneous pneumothorax after prior talc pleurodesis: a feasible, safe and efficient treatment option. Eur J Cardiothorac Surg  2004; 26: 889– 92. Google Scholar CrossRef Search ADS PubMed  13 Cardillo G, Facciolo F, Regal M, Carbone L, Corzani F, Ricci A et al.   Recurrences following videothoracoscopic treatment of primary spontaneous pneumothorax: the role of redo-videothoracoscopy. Eur J Cardiothorac Surg  2001; 19: 396– 9. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

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European Journal of Cardio-Thoracic SurgeryOxford University Press

Published: Apr 1, 2018

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