Lung wedge resection: Is it necessary for stages I and
II primary spontaneous pneumothorax
BY
Mohamed Khairy MD, Department of cardiothoracic surgery, Benha Faculty of Meddicine,
Benha University
Abstract
OBJECTIVES: To evaluate the role of apical lung wedge resection in patients with recurrent
primary spontaneous pneumothorax with no endoscopic evidence of blebs or bullae at surgery
as compared with simple apical pleurectomy.
METHODS: We performed video-assisted thoracoscopic surgery (VATS) in 130 patients of
them 58 were treated for stage I and II recurrent PSP between July 2003, to September, 2008.
Vanderschueren’s classification was used for staging. Surgical indications were: stages I and
II, subtotal pleurectomy (28 patients, group A) and subtotal pleurectomy together with an
apical lung wedge resection (30 patients group B); stages III and IV, stapling of the bullae and
subtotal pleurectomy. Differences in recurrence rates were calculated to compare the specific
procedures.
RESULS: No postoperative deaths occurred. Complication rate was 11.5%. Mean follow-up
was 35.9 months (range, 7 to 48). Overall recurrence rate was 4.6%. Four patients in group A
(14.2%) experienced recurrent ipsilateral pneumothoraces 32 to 65 weeks (mean, 44) after the
operation. No recurrences were observed in group B (P < 0.05).
CONCLUSIONS: In this selected group of patients without visible blebs or bullae apical
pleurectomy should be accompanied by apical lung wedge resection even for this favorable
category of patients.
Introduction
Primary spontaneous pneumothorax is (PSP) a common disease defined as the
accumulation of air in the pleural space with secondary lung collapse. Treatment
options vary greatly from observation to operation. Conservative treatment, including
observation, aspiration, and tube thoracostomy, is usually the first-line treatment for
primary spontaneous pneumothorax (1). Other options include pleurodesis with
instillation of tetracyclin, talc, or other pleural irritants, apical parietal pleurectomy
through video-assisted thoracoscopic surgery (VATS), and apical lung wedge
resection as an adjunct or solitary treatment. Recurrence rates with VATS or open
surgery vary between 1% and 14% (2-6), while nonsurgical approaches are associated
with recurrence rates of 8% to 25% (2, 7). In elective patients with recurrent PSP
without blebs or bullae (Vanderschueren stage I-II) and without air leak at surgery,
conflicting evidence exists as to whether VATS should be accompanied by apical
lung wedge resection (8). In those patients two surgical strategies have historically
evolved. One strategy emphasizes a simple pleurectomy; the other adds a routinely
performed apical lung wedge resection. (9)
The aim of this study was to evaluate the role of apical lung wedge resection in
patients with no detectable blebs or bullae during VATS as compared with the
conventional approach of simple apical pleurectomy.
Patients and methods
From July 2003, to September, 2008, 130 patients underwent VATS for treatment of
recurrent PSP. There were 112 male (86.1%) and 18 female patients (13.9%); mean
age: 21.4 years, range: 12 to 32 years. Eight patients had a second VATS procedure
for PSP of the other lung after a mean period of 22 months (range, 6 to 58).
Surgical technique
All procedures were performed with the patient under general anesthesia and one lung
ventilation. The patient was placed in the lateral position with the arm held abducted
to allow maximum superior displacement of the scapula. The first incision was always
placed in the fifth or sixth intercostal space in the midaxillary line, and a 0-degree
telescope connected to a video camera was introduced through a 10.5 mm trocar
sleeve. Two further trocars were introduced, under thoracoscopic control, respectively
through the fourth intercostal space in the anterior axillary line, and through the fifth
intercostal space in the auscultatory triangle. The lung was inspected during gentle
ventilation with saline in the pleural cavity to detect air leak or small blebs and bullae.
The pathologic lung lesions that were diagnosed endoscopically were classified
according to Vanderschueren’s classification (8): stage I: no endoscopic
abnormalities; stage II: pleuropulmonary adhesions; stage III: blebs/bullae less than 2
cm; stage IV: bullae more than 2 cm. Patients with stage I and II were categorized
into two groups: group A routinely received a subtotal pleurectomy, and group B
received a subtotal pleurectomy together with a standardized apical lung wedge
resection that was performed by means of the endoscopic stapler. In patients with
stages III and IV treatment of blebs/bullae was by stapling and subtotal pleurectomy.
Endoscopic parietal pleurectomy was performed according to Inderbitzi and
colleagues (10): the fifth rib represents the caudal limit of the pleurectomy. The
longitudinal paravertebral limit provides the anatomic guideline for the sympathetic
nerve. The pleural incision is made 1 cm to the side of the nerve to avoid damage by
the (monopolar) coagulation hook and runs apically to the level of the left subclavian
artery, or, on the right side, the brachiocephalic trunk, anteriorly incision is made 1 cm
to the side of the internal mammary vessels. At the end of the surgical procedure,
usually one drain (28 French gauge) was properly guided to the apex and the lung
inflated at an inspiratory hold of 30 mm H2O.
Statistical analysis
Demographic, medical, intraoperative, and postoperative data were collected on all
patients. Continuous variables are expressed as mean ± SD. Categorial variables are
expressed as percentages. After testing for normality of distribution, continuous
variables were compared using Student's t- test. Categorial variables were compared
using Z-test.
Results
Videothoracoscopic evaluation of the lung accomplished according to
Vanderschueren’s classification showed that stage I was 38 (29.2%) cases; stage II: 20
(15.4%) cases ( both were classified together into group A,28 patients and group B,30
patients); stage III: 56 (43.1%) cases; and stage IV: 16 (12.3%) cases.
There were no postoperative deaths. In patients with stage I and II intraoperative
complication rate was 1.7% (one patient in group B) due to injury to the third
intercostal artery that was treated thoracoscopically by monopolar coagulation,
postoperative complication rate was 10.3% (6 of 58); it included 3 cases (2 in group A
and 1 in group B) of localized pleural effusions, 2 apical hematoma (groupB) and 1
transient Horner syndrome (group A). The transient Horner syndrome occurred after
monopolar coagulation of apical bleeding point after pleurectomy. No prolonged air
leak was observed in both groups. Chest tubes were removed after a mean duration of
32 hours (range, 24 to 48) in group A and after 38 hours (range, 24 to 78) in group B
(p > 0.05). The mean hospital stay was 2.4 days (range, 2 to 5) in group A and 3 days
(range, 2 to 7) in group B (p > 0.05)( Table1). In all patients of group B, histologic
examination confirmed absence of any subpleural blebs or bullae.
Prolonged air leaks (>5 days) occurred in 6 cases, 2 cases, stage III and 4 cases in
stage IV. They resolved spontaneously. Three cases of localized pleural effusions
occurred in stage IV.
Table 1. Clinical Data and Follow-Up
Intraoperative
complication
Postoperative
complication
Chest tube duration
(hours)
In-hospital
stay
(days)
Recurrences (n)
Group A(N=28)
0 (0%)
Group B(N=30)
1 (3.3%)
P-Value
< 0.05
3 (10.7%)
3 (10%)
> 0.05
32
38
> 0.05
2.4
3
> 0.05
4 (14.2%)
0 (0%)
< 0.05
Follow-up was complete in all patients and the mean follow-up period was 35.9
months (range, 7 to 48).
Recurrent pneumothorax was seen in 6/130 (4.6%) patients, 4 recurrences in stage I-II
(all in group A), 1 in stage III and 1 in stage IV(Table 2). No recurrences were seen
after pleurectomy together with an additional apical lung wedge resection (group B).
Recurrences occurred in group A 32 to 65 weeks (mean, 44) after the operation.
Pneumothoraces always developed in the lower part of the chest and never in the
apex. One recurrence in stage III occurred 9 months after surgery and one recurrence
in stage IV occurred 12 months after surgery. All recurrent cases underwent surgical
revision and total pleurectomy through minithoracotomy. During surgery all patients
presented with massive apical adhesions in the area of the initial pleurectomy.
Statistical analysis revealed significantly lower recurrence rates in patients with group
B in comparison with group A (Z = 2.12, P< 0.05).
Table 2. Recurrent pneumothorax after VATS
Stage
Stage I-II (group A)
Stage I-II (group B)
Stage III
Stage IV
Procedure
Subtotal pleurectomy
Subtotal pleurectomy
apical wedge resection
Subtotal pleurectomy
Stapling
Subtotal pleurectomy
Stapling
Recurrence rate (%)
4/38 (10.5%)
+ 0/20 (0%)
+ 1/56 (1.7%)
+ 1/16 (6.2%)
Comment
In patients with recurrent pneumothorax, the recurrence rate is very high:
approximately 50% after a second episode and 80% after a third episode so that
surgery is mandatory (8). Another indication for surgery is failure of chest drainage of
a first episode of PSP (persistent air leak longer than 5 days; failure of lung
expansion). In the field of surgical treatment of PSP, VATS has become more popular
than thoracotomy and currently it probably represents the gold standard of the therapy
even if there is a lack of large-scale controlled studies (11). Comparing the results of
VATS and conventional surgical therapy in the treatment of recurrent spontaneous
pneumothorax, the mean recurrence rate after VATS was higher than the mean
recurrence rate after conventional standard thoracotomy and very close to the results
of transaxillary minithoracotomy: respectively, 4%, 1.5%, and 4.6% (12, 13, 14).
In the literature, the classification of PSP by Vanderschueren forms the basis of
decision making concerning staged surgical approach. Stage I and II patients without
bullae at surgery are treated by pleurodesis (pleurectomy or talc poudrage), whereas
patients in stage III and IV receive additional treatment of the bullae either by ligation
or stapling (8).
In a large study of 622 patients treated with traditional thoracoscopy, Van der Brekel
and associates reported no pathomorphological changes in 45% of cases (15). In a
study of 79 patients treated with VATS, Inderbitzi and colleagues, showed no
pathomorphologic changes in only 5.1% of cases (10). In the present report, a normal
lung (stage I) was found in 38 of 130 patients (29.2%).
In this selected group of patients without endoscopical abnormalities, VATS offers
low recurrence rates through a minimally invasive approach. However, data suggest
that apical pleurectomy should be accompanied by apical lung wedge resection even
in this favorable category of patients because evidence of bullae during the evaluation
of a primary spontaneous pneumothorax (PSP) is not predictive of recurrence (2).
Interestingly, Cardillo and colleagues showed that the overall recurrence rate in
patients with no evidence of blebs (stages I and II) was 5.37% after subtotal
pleurectomy or talc poudrage, whereas the best results, with a recurrence rate of 0%
and 0.84%, were achieved in stage III and IV patients respectively treated by stapling
of the bullae and pleurodesis (8). Such data are in agreement with Naunheim and
colleagues: in their article, the recurrence rate when no blebs had been identified was
27.3% versus 0% and 2.7%, respectively, when one or multiple blebs were identified
(16). These results support our observations of superior long-term freedom from
recurrence in stage I-II (group B) as well as in stage III and IV patients treated by
apical pleurectomy in combination with apical lung wedge resection.
The general understanding of the underlying mechanism of the development of PSP is
the rupture of a subpleural bleb into the free pleural space. It is further a well-known
situation to every chest surgeon that, even if we can identify blebs in the typical areas,
we are not always able to verify an air leak. On the other hand, we see patients with
spontaneous mediastinal emphysema without pneumothorax. An alternative
explanation of the underlying pathway seems to be very attractive in this concern:
After bullae have formed, inflammation-induced obstruction of the small airways
increases alveolar pressure, resulting in an air leak into the lung interstitium. The air
then moves to the hilus, thereby causing pneumomediastinum; as mediastinal pressure
rises, rupture of the mediastinal parietal pleura occurs, causing pneumothorax (2).
Histopathological analysis and electron microscopy of tissue obtained at surgery have
not shown that there is a defect in the visceral pleura through which air escapes from
bullae into the pleural space (17). This theory may well serve as an explanation for the
significantly superior results after combined segmental resection and pleurectomy.
Simple pleurectomy does not seem to prevent rupture of blebs into the parenchyma
and the indirect development of pneumothorax (9).
In conclusion, patients with recurrent spontaneous pneumothorax without endoscopic
evidence of blebs or bullae, apical pleurectomy should be accompanied by apical lung
wedge resection even for this favorable category of patients.
References
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2. Sahn S., Heffner J. Spontaneous pneumothorax. N Engl J Med 2000;342:864868.
3. Bertrand P., Regnard J., Spaggiari L., et al. Immediate and long-term results
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4. Mouroux J., Elkaim D., Padovani B., et al. Video-assisted thoracoscopic
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‫الملخص العربي‬
‫إستئصال جزء من الرئة‪ :‬هل هو ضرورى فى حاالت المرحلة االولى والثانية‬
‫لالسترواح الهوائى االولى‪.‬‬
‫يهدف هذا البحث الى دراسة مدى تأثير استئصال جزء مزا ال زل الى زنى مزا الر زة‬
‫ع ززى اتززا ج عززت لززالة الورل ززة اليلززى يالالاايززة االتززى لينجززد هززا لنيصززتة ي‬
‫كياس هنا ية الر ة) لتسترياح الهنا ى اليلى ‪.‬‬
‫الخطززة ززى ال تززرن مززا يا ‪ 2008 – 2003‬تززع عو ز ‪ 130‬منظززار رززدرى لحززالة‬
‫استرياح هنا ى يلى يكزا مزا يزنهع ‪ 58‬مزري رزن نا اهزع زى الورل زة اليلزى‬
‫يالالااية لهذا الورض‪ ,‬تع تقسيوهع الى مجونعتيا‬
‫اليلززى ‪ A‬ا‪ 28‬مززري ) تززع ززيهع عوز استئصززال ل جززء الى ززنى ل ززا الب ززنرى‬
‫الوبطا لجدار الصدر‪.‬‬
‫الالاايززة ‪ B‬ا‪ 30‬مززري ) تززع ززيهع عو ز استئصززال ل جززء الى ززنى ل ززا الب ززنرى‬
‫الوبطا لجدار الصدر الضا ة الى استئصال الجء الى نى ما ال ل الى نى ل ر ة‪.‬‬
‫مززا ززالى الورضززى قززد تززع ززيهع الضززا ة لوززا جززرى ززى الوجونعززة ‪ B‬عوز تززد ي‬
‫لتكياس يالحنيصتة الهنا ية‪.‬‬
‫تع متا ىة الورضى ل ترن متنسطها ‪ 35,9‬شزهرا يللزل لدراسزة مىزدل لزديج ارتجزا‬
‫لتسترياح الهنا ى يهع‪.‬‬
‫النتا ج لع تحدج ي ياة ى هؤل الورضى‪ ,‬يكا مىدل لديج ارتجا لتسزترياح‬
‫الهزززنا ى ززز جويزززه الورضزززى هزززن‪ %4,6‬مزززا مرضزززى الوجونعزززة ‪ A‬كزززا مىزززدل‬
‫الرتجزززا زززيهع هزززن‪ %14,2‬مقا ززز رززز ر‪ %‬ل وجونعزززة ‪ ,B‬يكزززا للزززل لي دللزززة‬
‫الصا ية‪.‬‬
‫الخترة يستخ ل منهذا البحث اه يجب عو استئصال ل جء الى زنى مزا ال زل‬
‫الى نى ل ر ة ى مرضى الورل ة اليلى يالالااية ع زى الزر ع مزا عزدو يجزند كيزاس‬
‫ي لنيصززتة هنا يززة الر ززة ل للززل يق ز مززا التوززال لززديج ارتجززا لتسززترياح‬
‫الهنا ى‪.‬‬