In fact, all patients with spontaneous pneumothorax have some underlying lung disease only without clinical manifestations. Subpleural air bubbles are most often found during surgery. Those patients with underlying disease that can lead to pneumothorax are described as “secondary pneumothorax” and are further classified as having airway disease, infectious disease and interstitial lung disease. The identification of spontaneous or secondary pneumothorax facilitates the treatment of the pneumothorax along with the primary disease. This group of patients is not discussed in this article.
In patients with spontaneous pneumothorax, the clinical symptoms are pleuritis-like chest pain and shortness of breath, and many patients are sent to the emergency room. Usually the first contact of the patient is with an emergency or medical physician and rarely goes directly to a surgeon. Most patients are observed or have closed chest drains, and only when a pneumothorax recurs is there some level of consensus for surgical intervention.
However, there is still a debate about the place of surgery in the treatment. Unfortunately, many of the treatment choices are based on local medical traditions and the personal experience of professionals. The intention of this article is to review the literature and summarize the role of surgical interventions, particularly VATS pleural fixation, after failure of initial treatment of spontaneous pneumothorax. The aim is to give guidance to surgeons in choosing the timing and modality of intervention.
To this end, we highlight 5 common clinical questions in particular
1. When to perform surgical interventions.
2. Whether preoperative chest CT is routinely performed.
3. Which surgical intervention (VATS vs. small axillary incision).
4.Whether the surgical approach is alveolar resection or pleural fixation.
5. How to manage the drainage tube after surgery. The recommended grade was based on the American College of Chest Physicians (ACCP) Physician Specialty Panel grade recommendations and clinical guidelines for quality of evidence.
Methods
Most of the current principles of treatment of spontaneous pneumothorax are based on the clinical guidelines of the American College of Chest Physicians (ACCP) 2001 [4] and the British Thoracic Society (BTS) 2003 [5]. However, both have not been updated since their publication. In this section we use this as a basis to focus on the role of thoracoscopic pleural fixation in the treatment of spontaneous pneumothorax.
To identify new evidence to change the clinical guidelines, we searched both entries from Pubmed.
A total of 19 papers were found, and 12 were screened to meet the criteria for surgical treatment of spontaneous pneumothorax. These articles serve as the core reference for this article, and the main purpose is to change or clarify some ACCP or BTS guidelines through these article views.
Some issues related to clinical
Choice of surgical timing
If surgery is required for spontaneous pneumothorax, when is it more appropriate?In 2001 ACCP published an opinion in Delphi (based on expert opinion and literature review) regarding the treatment of spontaneous pneumothorax. The opinion states that surgical treatment should be considered for spontaneous pneumothorax with chest tube drainage for more than 4 days and still leaking air, unless surgery is contraindicated to consider chest tube adjustment or intrathoracic injection of sclerosing agents.
The 2003 BTS similarly recommends surgical intervention after 3-5 days of persistent air leak (based on expert opinion and review of the literature). However, some internists are reluctant to consider surgical procedures because they believe that these patients will heal on their own after sufficient time. In fact, these reasons are flawed in at least two ways. First, they ignore the fact that surgical finger treatment can reduce the duration of chest tube substitution and hospitalization.
A recent study comparing VATS or insistent tube drainage in patients who required prolonged tube substitution showed that VATS had the advantages of shorter hospital stay, lower complications, and lower recurrence rates. Second, they also ignored the fact that prolonged treatment with a tube is prone to infection or bronchopleural fistula. In such cases, the treatment cost and risk are increased by surgical intervention.
Therefore, surgical treatment at the first pneumothorax has been suggested. An interesting quality-of-life adjustment analysis regarding VATS was performed by a Japanese physician [7], in which the authors suggested that VATS treatment could be considered at the first pneumothorax as long as the operative mortality rate was less than 0.3%. This is far from the clinical guidelines of the two major organizations, where both ACCP and BTS recommend that surgical treatment be considered only if drainage fails or if drainage exceeds 4 angels.
Routine CT examination
In 2001, ACCP did not recommend routine CT for the first pneumothorax, but did not agree on whether CT should be performed for pneumothorax with persistent air leak requiring surgery. 2003, BTS recommended CT for complex pneumothorax or suspected malpositioned chest tube with indistinct subcutaneous emphysema on plain chest radiograph, but did not explicitly recommend routine preoperative CT. CT is not routinely recommended.
However, many physicians are willing to perform preoperative CT in order to locate a definite alveolus. A prospective study has shown that preoperative CT can clarify the presence or absence of pulmonary alveoli in the countermeasure of patients with pneumothorax [8]. The authors suggested that CT could predict the risk of pneumothorax in the contralateral thorax and give preventive surgical intervention. However, there is no other information to support routine preoperative CT, much less preemptive contralateral thoracic surgical intervention.
Therefore, there is no evidence for or against routine preoperative CT of spontaneous pneumothorax, and the decision to perform CT should be based on patient characteristics and the physician’s own clinical judgment.
Surgical pathway
The 2001 ACCP clinical guidelines recommend a thoracoscopic approach for pneumothorax with persistent air leakage. The guidelines also recommend an axillary open-chest approach without muscle damage, rather than a standard thoracoscopic and sternotomy approach. In contrast, the BTS recommends standard open-chest surgery to mitigate the recurrence rate of pneumothorax, with thoracoscopy as an alternative option.
Some of the available evidence remains unclear regarding the superiority of thoracoscopy over open-heart surgery. There is a systematic review of randomized trials on VATS, which included 6 randomized trials on VATS versus conventional open chest analysis (2 versus chest tube drainage and 4 versus open chest surgery) in a total of 327 patients and concluded that VATS has better clinical outcomes and lower complication rates.
Another meta-analysis including 4 randomized trials and 25 non-randomized trials showed the opposite results. This analysis showed that the recurrence rate of thoracoscopic pneumothorax was 4%, while the recurrence rate of conventional open thoracotomy was less than 1%, and considered open thoracotomy as the gold standard for the treatment of spontaneous pneumothorax. However, experts believe that the 2 randomized trials and most of the nonrandomized trials in this analysis occurred before the maturation of VTAS technology.
A recent prospective analysis of the two procedures showed that VATS has better clinical outcomes especially in terms of postoperative chest pain. Based on the above evidence, we recommend VATS as the preferred option, with axillary open-heart surgery without muscle injury as an alternative.
Intraoperative pleural fixation
Is pleural fixation required in conjunction with alveolar resection? Although there are various surgical options for spontaneous pneumothorax, the main one is suturing or stapling or removal of the alveoli. However, alveolar resection alone may be associated with a high recurrence rate. A retrospective comparative study showed a 16% recurrence rate of pneumothorax with alveolar resection alone, compared to 1.9% with concurrent pleural fixation. It is not clear then whether pleural fixation is achieved by mechanical rubbing or resection of the pleura or by thoracic injection of a sclerosing agent. the ACCP recommends thoracic rubbing or pleurodesis at the top of the chest to achieve pleural fixation, and there is no clear agreement on the use of talc fixative.
The use of thoracoscopic pleural friction may reduce the incidence of complications, especially hemothorax. A recent report showed a 7.4% incidence of hemothorax with pleurodesis at the top of the chest compared to 0.9% with pleurodesis friction. The recurrence rate of pneumothorax was essentially the same in both groups. A randomized clinical trial examined whether the addition or absence of a chemical pleural fixative after VATS pleurodesis with pleurodesis affected the recurrence rate of pneumothorax. This randomized study was a bedside chest tube injection of dimethylaminetetracycline compared to conventional chest tube management after VATS alveolar resection with mechanical fixation of the pleurodesis.
The resultant authors found a mild reduction in recurrence for those using pleural fixation, but a significant increase in pain offset the reduction in chest pain from thoracoscopy. Therefore, it is unclear whether this supports the use of pleural fixation for recurrence reduction based on patient characteristics. Currently, there is no clear evidence to support the use of pleural fixation.
The BTS clinical guidelines suggest that talc can be used alone for spontaneous pneumothorax, but not at first treatment due to the high failure rate (9% higher than surgical treatment) and the fact that this foreign body remains in the body forever. In the United States talc is only used as an option after failure of pleural friction after other fixation agents have failed. In contrast, several recent retrospective analyses in Europe have concluded that VATS plus talc fixation is safe and effective.
A large group of single-center experiences reported on 861 patients comparing the treatment outcomes of VATS alveolar resection alone with the addition of talc fixation. Although both primary and recurrent pneumothorax patients were included in this group, the overall pneumothorax recurrence rate was 2.41% for surgery alone and 1.73% for the addition of talcum powder. This result suggests that we can use talc fixative at home during spontaneous pneumothorax surgery. However, in the absence of convincing further studies, the current ACCP is still not recommended. Currently, it is considered that the best treatment option for spontaneous pneumothorax is VATS alveolar resection plus the use of mechanical pleural fixation.
Management of thoracic drainage tubes
Does postoperative chest drainage after spontaneous pneumothorax require negative pressure suction or water seal bottle drainage? There is much debate regarding the modality of postoperative chest drainage. While clear pleural contact is necessary for pleural fixation, is negative pressure chest tube drainage necessary once the lung is well inflated with good pleural contact in the dirty wall? Or is water-sealed bottle drainage more likely to speed up extubation time? However, neither ACCP nor BTS provides specific guidance on the management of chest drains.
A single-center randomized trial compared the use of negative pressure suction or water seal bottle drainage for chest drainage after spontaneous pneumothorax surgery. All patients were initially treated with negative chest tube suction, and once the patients recovered well and were transferred to the general ward, they were randomized to two groups: continued negative pressure suction and water-sealed bottle drainage. The results showed that the water-sealed bottle group had a shorter duration of chest drainage (2.7 vs. 3.8 days, p = 0.004) and a shorter hospital stay (3.7 vs. 4.8 days, p = 0.004).
There are no other data to study the management of chest drains after VATS for spontaneous pneumothorax. However, there are some additional data from double-blind controlled trials showing that water-sealed bottle chest drains after lung resection have a shorter hospital stay [20-22]. The data suggest the application of water-sealed bottle drainage after lung expansion after VTAS for spontaneous pneumothorax.
Conclusions and recommendations
VATS pulmonary alveolar resection stapling plus mechanical or chemical pleural fixation is recommended to be safe and effective in patients with spontaneous pneumothorax with pleural air leak for more than 4 days or after rethoracic drainage.