Professional Documents
Culture Documents
DOI: 10.1183/09031936.06.00014206
CopyrightERS Journals Ltd 2006
AFFILIATIONS
*Valais Pneumology Centre, CransMontana, Switzerland,
#
Thoracic Surgery Service, Mutual
Hospital of Terrassa, University of
Barcelona, Terrassa, Spain,
"
Interventional Endoscopy Clinic,
Anaesthesiology Dept and
Respiratory Division, University
Hospital AZ VUB, Brussels, Belgium,
+
Dept of Pulmonary Diseases and
UPRES 3287, Division of Thoracic
Oncology, Saint Marguerite Hospital,
Marseille, France.
CORRESPONDENCE
J-M. Tschopp
Reseau Sante Valais
Centre Valaisan de Pneumologie
3963 Crans-Montana
Switzerland
Fax: 41 276038181
E-mail: Jean-marie.tschopp@
admin.vs.ch
Received:
January 30 2006
Accepted:
May 03 2006
Previous articles in this series: No. 1: Bolliger CT, Sutedja TG, Strausz J and Freitag L. Therapeutic bronchoscopy with immediate effect: laser,
electrocautery, argon plasma coagulation and stents. Eur Respir J 2006; 27: 12581271. No. 2: Vergnon J-M, Huber RM and Moghissi K. Place of cryotherapy,
brachytherapy and photodynamic therapy in therapeutic bronchoscopy of lung cancers. Eur Respir J 2006; 28: 200218. No 3: F. Rodriguez-Panadero, J.P. Janssen
and P. Astoul. Thoracoscopy: general overview and place in the diagnosis and management of pleural effusion. Eur Respir J 2006; 28: 409421.
VOLUME 28 NUMBER 3
c
637
Conservative
Observation
Conservative treatment
Aspiration
Intermediate
Invasive
Pleurodesis
Pleurectomy
Cauterisation
Bullectomy
Pleural abrasion
Tube drainage
VATS
Thoracotomy
Medical thoracoscopy
VATS: video-assisted thoracoscopic surgery.
638
VOLUME 28 NUMBER 3
TABLE 2
Airway disease
Chronic obstructive pulmonary disease
Cystic fibrosis
Acute severe asthma
Infectious lung disease
Pneumocystis carinii peumonia
Tuberculosis
Necrotising pneumonia
Interstitial lung disease
Sarcoidosis
Idiopathic pulmonary fibrosis
Histiocytosis X
Lymphangioleiomyomatosis
Connective-tissue disease
Rheumatoid arthritis
Ankylosing spondylitis
Polymyositis/dermatomyositis
Scleroderma
Marfans syndrome
Ehlers-Danlos syndrome
Cancer
Lung cancer
Sarcoma
FIGURE 1.
Mechanisms of pleurodesis
Pleurodesis for the management of SP is intended to achieve
symphysis between parietal and visceral pleura and to prevent
VOLUME 28 NUMBER 3
639
10
VAS score
8
6
4
2
0
FIGURE 2.
Day
(h) and pleural drainage (&) during and after each procedure. Data are presented
as meanSD. Pain was not significantly higher after thoracoscopic talcage than
pleural drainage provided use of opioids in both groups. Adapted from [44].
VOLUME 28 NUMBER 3
Although talc remains in the pleural space for a long time after
administration, there appear to be relatively few long-term
effects, in particular impairment of lung function [65, 80].
b)
FIGURE 3.
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641
FIGURE 4.
VOLUME 28 NUMBER 3
a)
b)
abrasion, the parietal pleura looks normal (a); as abrasion is in progress, the
parietal pleura is reddened and bleeds slightly (b).
643
These methods have not been used in the most recent series.
Recurrence rates also seem to be inversely related to the
intensity of the treatment; the more procedures performed,
especially when lung and pleural procedures are combined,
the fewer the recurrences. In an uncontrolled series of 74
patients treated with four different methods, the recurrence
rates for each procedure were: ligation of air leak, 11.5%;
wedge resection of blebs or bullae, 7.1%; pleurectomy, 6.35%;
and pleurectomy plus ligation of air leaks or wedge resection
of lesions, 5.6% [101]. In 113 patients, the only independent
predictive factor of recurrence of SP was the failure to identify
and resect a bleb at operation [104]. In recent series, the
procedure of choice is stapled resection of blebs and bullae, or
wedge resection of the tip of the lung when lesions are not
identified, and some sort of pleurodesis: mechanical abrasion,
apical pleurectomy or patchy electrocoagulation of the parietal
pleura. These procedures result in a recurrence rate of 05%
[18, 102, 105108, 110, 113115, 121]. Pleural procedures alone
are associated with higher recurrence rates, 6.3% for apical
pleurectomy [101] and 9.9% for mechanical pleurodesis [102].
Complete pleurodesis prevents recurrences better than partial
pleurodesis. In 339 Vanderschueren stage III and IV patients,
PSP was treated with either ligation or stapling of lesions and
subtotal pleurectomy or talc poudrage; those treated with talc
poudrage showed the lowest recurrence rates: 0 versus 4.5% for
stapling and poudrage, and ligation and poudrage in stage III
pneumothorax; and 0.84% for stapling and poudrage for stage
IV pneumothorax. However, the recurrence rates for the same
pneumothorax stages when subtotal pleurectomy was performed instead of poudrage were 4.70, 12.19 and 5.26%,
respectively. The same was observed in 93 patients with stage I
and II PSP treated with either subtotal pleurectomy or talc
poudrage alone, in whom recurrence rates were 6.45 and 4.8%,
respectively [67].
Long-term complications include moderate chronic pain,
usually located in the area of the trocar incisions, in about a
third of patients, especially in those who have undergone
pleurectomy as compared with mechanical pleurodesis.
However, ,4% require daily medication [107]. Additionally,
,50% of patients may experience chest wall paraesthesiae,
distinct from wound pain [122]. These chronic complications
seem to be due to compression of intercostal nerves during
operation. Some authors use trocars for the thoracoscope only,
and insert the other instruments through the intercostal
incisions in the other ports in order to minimise nerve
compression. The use of needlescopic instruments (2 mm in
diameter) has been found to reduce post-operative wound
pain [123] and residual neuralgia [124]. The presence of dense
pleural adhesions is an indication for conversion to standard
VATS [125]. Although published experience is scarce, needle
thoracoscopy seems to be as effective as conventional VATS
when there are bullae of ,2 cm and few pleural adhesions.
Treatment of recurrences varies according to the size of
pneumothorax and the presence of air leaks after insertion of
chest tubes. For limited pneumothorax in stable patients, rest
and observation are recommended. When reoperation is
necessary, both repeat VATS and thoracotomy have been
performed. In ,50% of cases, residual bullae or air leaks are
found; these are usually stapled or ligated, and pleurodesis by
pleurectomy, abrasion or talc poudrage is added. When no
644
VOLUME 28 NUMBER 3
VOLUME 28 NUMBER 3
CONCLUSION
There are many options in the management of SP. Its
pathophysiology remains poorly understood. However, it is
very well known that PSP is strongly related to smoking in
both sexes. No clinician should miss the opportunity of
pneumothorax, especially in young people, to encourage
smoking cessation. Most young patients continue to smoke
after their first episode of PSP, showing that clinical strategies
need to be improved in order to better address the needs of this
particular age group [144].
645
As shown in the present article, thoracic surgeons and pulmonologists must develop more synergies and use randomised
controlled trials in order to improve on the knowledge
accumulated by both disciplines for the management of
pneumothorax, since most studies to date have been nonrandomised controlled studies. This is the only way to answer
the rather provocative question asked by surgeons as to
whether the tendency to replace simple thoracocoscopy with
video-assisted thoracoscopic surgery might not be due to the
glory of newer and expensive techniques [64]. In 1997 [152], an
editorial welcoming the fifth anniversary of video-assisted
thoracoscopic surgery reported, at that time, .500 publications
on video-assisted thoracoscopic surgery and concluded that
most of theses publications represented very little careful
scientific evaluation of this new technology. It is now time to
evaluate more scientifically an old technique, thoracoscopy,
discovered by Jacobeus in 1910 [10], and also video-assisted
thoracoscopic surgery, which has been available since 1992.
This is the only way to diminish the present confusion
regarding the best treatment for pneumothorax [153].
ACKNOWLEDGEMENTS
The authors would like to thank J. Brunton for comments and
suggestions.
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