Dual port VATS for recurrent spontaneous pneumothorax: Foroulis et. al

A newly published study comparing dual port thoracoscopy with mini-thoracotomy for the treatment of recurrent spontaneous pneumothorax

Here at cirugia de torax, we take a keen interest in the development of increasingly minimally invasive technologies from dual (and single-port) thoracoscopy for a variety of conditions to RATS (robot- assisted thoracic surgery).  It is our belief that by embracing these emerging technologies, we help to advance the thoracic surgery specialty.

This spring, we have had the pleasure of publishing case reports on dual port thoracoscopy for decortication of parapneumonic effusions and empyema and catching up with one of the leaders in single incision thoracic surgery, Dr. Diego Gonzalez Rivas.

This month, another entry, “A modified two-port thoracoscopic technique versus axillary minithoracotomy for the treatment of recurrent spontaneous pneumothorax: a prospective randomized study,”  by Dr. Christophoros N. Foroulis at the Aristotle Medical School in Thessaloniki, Greece was published in Surgical Endoscopy.  As noted in a previous post, there have been few (if any) published papers on dual port thoracoscopy, and no comparison studies of these two techniques.

This study, which was conducted during 2006 to 2009 followed 66 patients who were randomly assigned to receive either mini-thoracotomy or dual-port VATS for surgical pleurodesis/ bullectomy / blebectomy.

In this study, despite random assignment, each group of 33 patients were well matched in all characteristics such as age, operative side and BMI.   After surgical treatment, patients were followed for a median of 30 months (range 3 – 53 months) for development of late complications or recurrent pneumothorax.

Each treatment group – VATS versus open surgical was overseen by one surgeon with Dr. Foroulis performing all of the dual port surgeries, and Dr. Papakonstantinou performing all of the open procedures.  Outcomes were independently reviewed / evaluated by the remaining authors.

Study Findings

–  No conversions to open thoracotomy from the VATS group.

– Similar rate of recurrence between open (2.7%) and VATS (3%) group (but timing of recurrence differed.)  Both recurrent pneumothoraces in the VATS group occurred early post-operatively (POD#5) compared to the open surgical group – 13 months post-op.

– Rate of complications the same between groups but the type of complications differed. 2 patients in each group required reoperation:

VATS – reoperation for prolonged airleak

Minithoracotomy group – hematomas/ evacuation of clots

Length of stay (LOS) and post-operative pain

Surprisingly, length of stay and post-operative pain – two of the outcomes that are usually cited in favor of minimally invasive procedures – were not significantly different between the groups.

Differences

Patient satisfaction

However, patient satisfaction was significantly higher in the dual port group.  This was related to an earlier return to normal activities, and earlier full mobilization of the affected arm.

Longer procedures

VATS procedures were longer than open procedures – by a mean of 21 minutes (87.1 minutes for VATS versus 66.7 minutes for minithoracotomy) with associated increases in uni-lung ventilation time.

Discussion/ Conclusions

While previous studies had reported a recurrence rate that was significantly higher in the VATS group – that was not seen here.  The ability to detect blebs/ bullae (and thus treat) with VATS remains limited in comparison to a mini-thoracotomy, but does not appear to change outcomes after a successful pleurodesis procedure.  Dual port thoracoscopy does take more time but both procedures appear equally effective.

Reference:

Foroulis, C. N., Anastasiadis, K., Charokopos, N., Antonitisis, P., Halvatzoulis, H. V., Karapanagiotidis, G. T., Grosomanidis, V. & Papakonstantinou, C. (2012).  A modified two-port thoracoscopic technique versus axillary minithoracotomy for the treatment of recurrent spontaneous pneumothorax: a prospective randomized study.  Surg Endosc 2012 May 12.  Includes color photographs of procedures.

Thank you to Dr. Foroulis for your assistance.

For more on related topics:

Case study: spontaneous pneumothorax

About spontaneous pneumothorax

Minimally invasive surgery: SITS

Case report: Blebectomy with talc pleurodesis after spontaneous pneumothorax

Case report of spontaneous pneumothorax followed by bleb resection and talc pleurodesis.

During my various travels and interviews, I have had the opportunity to meet and talk with thoracic patients from around the world.  During a recent trip, I encountered a very nice young woman (in her early 20’s**).  This is her story below:

The patient, the aforementioned young woman had no significant past medical history.  She initially presented to a small tertiary facility with chest pain.  She was evaluated for acute coronary syndrome and discharged from the emergency department.  She subsequently miscarried an early pregnancy.

Several days later, her symptoms intensified, and she became short-of-breath so she returned to the emergency department.  On chest radiograph, she was found to have a large left-sided pneumothorax.  A chest tube was placed but subsequent radiographs showed a persistent pneumothorax.  The nearest trauma facility was notified and the patient was transferred for further evaluation and treatment.

On arrival, the patient who was experiencing significant chest and LUQ pain, and breathlessness received a second chest tube.  Following chest tube placement in the emergency room, chest radiograph showed the pneumothorax to be unchanged.  The patient was admitted to the hospital for further testing.

A CT scan (TAC) of the chest showing chest tubes in good position and several large blebs.  Following the CT scan, thoracic surgery was consulted for further treatment and management.

After discussing the risks, benefits and alternatives with the patient and family, the patient elected to proceed with a left-sided VATS (video-assisted thoracoscopic surgery) with blebectomy and talc pleurodesis.

Patient received pre-operative low dose beta blockade for sinus tachycardia.  Patient was intubated with a double lumen ETT for uni-lung ventilation.  The patient was hemodynamically stable intra-operatively, and the case proceed without incidence.

Intra-operative thoracoscopy confirmed the presence of several blebs including a large bleb in the left lower lobe.  These were resected surgically with noncoated endoGIA staples.  (Coated coviden staples have been implicated in several injuries and fatalities previously.)

12 grams of sterile talc was insufflated using an aerosolized technique.  A new chest tube was placed at the conclusion of the case. There was minimal to no operative blood loss.

surgeon performing video-assisted thoracoscopy

The patient was awakened, extubated and transferred to the post-operative recovery unit.  Chest radiograph in recovery showed the lung to be well expanded on -20cm of suction.

Post-operatively the patient had a small airleak.  She was maintained on suction for 48 hours and watersealed.  Waterseal trials were successful, and on post-operative day #4, chest tube was removed.  Subsequent chest x-ray was negative for pneumothorax.  Patient was discharged home with a follow-up appointment and a referral to OB-GYN for additional follow-up.

Discussion: Due to patient’s history of miscarriage in close proximity to first reports of chest pain, special consideration was given to the possibility of catamenial pneumothorax (though this was first instance, and on the left whereas 90% of reported cases occur on the right.)  While the literature reports previous episodes of pneumothorax during pregnancy, these reports occurred in later gestation (37 and 40 weeks, respectively.)  On further evaluation, patient had no history of abnormal vaginal bleeding, pelvic infections, pelvic inflammatory disease or a previous diagnosis of endometriosis.  Thoracoscopic evaluation was negative for the presence of endometrial tissue, and there were no diaphragmatic defects.

Final pathology: no abnormal results, confirming intra-operative findings.

**Note:  Since this is a blog, available for public viewing, patient permission was obtained prior to posting.  All efforts are made to protect patient privacy, and thus details regarding patient demographics have been changed/ omitted.  Also, our gracious thanks to the patient and family for allowing this discussion of the case.  If you have an interesting, educational or informative case, contact Cirugia de Torax for publication.

For additional information and discussion on blebs and bullae, see our related post here.

Additional information and articles on catamenial pneumothorax:

Majak P, Langebrekke A, Hagen OM, Qvigstad E.  Catamenial pneumothorax, clinical manifestations–a multidisciplinary challenge.  Pneumonol Alergol Pol. 2011;79(5):347-50.

Ciriaco P, Negri G, Libretti L, Carretta A, Melloni G, Casiraghi M, Bandiera A, Zannini P.   Surgical treatment of catamenial pneumothorax: a single centre experience.   Interact Cardiovasc Thorac Surg. 2009 Mar;8(3):349-52. Epub  2008 Dec 16.

Sánchez-Lorente D, Gómez-Caro A, García Reina S, Maria Gimferrer J. Treatment of catamenial pneumothorax with diaphragmatic defects.  Arch Bronconeumol. 2009 Aug;45(8):414-5; author reply 415-6. Epub 2009 Apr 29. Spanish.

Alifano M, Jablonski C, Kadiri H, Falcoz P, Gompel A, Camilleri-Broet S, Regnard JF.  Catamenial and noncatamenial, endometriosis-related or nonendometriosis-related pneumothorax referred for surgery.  Am J Respir Crit Care Med. 2007 Nov 15;176(10):1048-53. Epub 2007 Jul 12

Kronauer CM.  Images in clinical medicine. Catamenial pneumothorax.  N Engl J Med. 2006 Sep 7;355(10):e9

Marshall MB, Ahmed Z, Kucharczuk JC, Kaiser LR, Shrager JB.  Catamenial pneumothorax: optimal hormonal and surgical management.  Eur J Cardiothorac Surg. 2005 Apr;27(4):662-6