C-shaped pleura cautery in primary spontaneous pneumothorax patients for pleurodesis.

BACKGROUND: Although pleurodesis is usually used to reduce the recurrence rate for primary spontaneous pneumothorax (PSP) in surgery, existing techniques cannot meet the higher requirements of little surgical injury and less relapse. Hence, we developed a new pleurodesis technique and named multipoint pleura cautery. AIM: In this study, we aimed to investigate the effectiveness and outcomes of the uniportal video-assisted thoracoscopic surgery C-shaped pleura cautery in the surgical treatment of PSP. To the best of our knowledge, this is a new surgical technique for pleurodesis and must be of concern. PATIENTS AND METHODS: The medical records of 20 patients undergoing surgery for C-shaped pleura cautery between 2015 and 2017 were reviewed. The patients were evaluated with regard to age, gender, body mass index, smoking habit, operation time, duration of hospitalization, post-operative pain and follow-up.
RESULTS: We have performed a bullectomy combined C-shaped pleura cautery for 20 patients with PSP from January 2016 to December 2017. None of the patients suffered post-operative bleeding and haematothorax complications, and one was ipsilateral relapsed 5 months after surgery. The lung computed tomography showed that recurrence of pneumothorax was due to air leakage in the right lower lung, and there was no air leakage at the site where pleurodesis had been performed.
CONCLUSIONS: Although this technique requires further investigation, it may be a useful method of pleurodesis.

INTRODUCTION

Primary spontaneous pneumothorax (PSP) is well known to have high recurrence rates if not treated appropriately.[1] The recurrence rate is approximate 32% for patients who underwent conservation treatment.[2] Video-assisted thoracoscopic surgery (VATS) that combines bullectomy with various pleurodesis procedures are the preferred treatment options for PSP.[3] Pleurodesis is defined as the symphysis between the visceral and parietal pleura that prevents the accumulation of either air or liquid in the pleural space. Currently, the commonly used mechanical pleurodesis in clinical practice includes partial pleurectomy and pleural abrasion, both of which are aimed at diffuse inflammation, formation of fibrin adhesions in the space by causing trauma to the pleura.[4] However, due to the higher incidence of relapse and complications, the optimal method of thoracoscopic pleurodesis after bleb resection is a matter of debate.[56]

Aim

In this study, we aimed to investigate the effectiveness and outcomes of the uniportal VATS C-shaped pleura cautery in the surgical treatment of PSP. To the best of our knowledge, this is a new surgical technique for pleurodesis and must be of concern.

PATIENTS AND METHODS

This study was a retrospective review of a prospectively maintained database. Between January 2016 and December 2017, 20 patients with PSP were underwent uniportal VATS bullectomy and pleura cautery. Indication for surgery was recurrence of PSP or persistent air leak for more than 5 days during the first episode of PSP. Patients' characteristics including age, gender, body mass index, smoking habit, operation time, duration of hospitalization, post-operative pain and follow-up were collected retrospectively [Table 1].

Table 1

Patient characteristics

Characteristics	Pleura cautery (%)
Age (years)	27.25±10.92
Sex
Male	18 (90)
Female	2 (10)
Laterality
Right	11 (55)
Left	6 (30)
Bilateral	3 (15)
BMI	19.95±2.38
Smoking habit	8 (40)
Recurrent pneumothorax	6 (30)
Operation time (min)	48.50±32.38
Persistent post-operative pain	0 (0)
Follow-up months	23.45±7.18

BMI: Body mass index

All patients were informed about the surgical procedure, the risks and the complications of the procedure before the operation, and written informed consent was obtained.

Surgical technique

Under separate lung ventilation, the patient is placed in a lateral position. VATS was performed with a single port. The uniportal technique involves a 2.5–3 cm incision placed in the third or fourth intercostal space in the midaxillary line. The video thoracoscope along with two roticulating instruments are then easily placed through the incision. A wedge resection of the bulla is performed using an endoscopic stapling device. Then, we begin to perform the pleurodesis. We use the ballpoint-electric to burn multiple points of the parietal pleura, along the intercostal space, ranging from the second to fourth intercostal space [Figure 1]. Multiple rounded scabs are connected to multiple C-shaped rings [Figure 2]. The level of burning should be superficial, with scab limited to the pleura is appropriate. Paying attention to do not hurt the intercostal nerve and blood vessels, especially great vessels and thoracic sympathetic trunk. The lung is re-expanded against the rough surface of the cauterized pleura to promote the whole apical pleurodesis. At the end of the surgery, one apical 24-French straight chest tube is placed and connected to a low (−5 cm H2O) continuous suction.

Figure 1

Using ballpoint-electric burning parietal pleura along the intercostal space

Figure 2

Multiple rounded scabs are connected to C-shaped rings

After operation, encouraging patients to cough is the most essential need. The chest tube is typically placed to water seal the following day. If no airleak is found, removing the thoracic tube as soon as possible.

RESULTS

We have performed and followed up 20 PSP patients in the Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University. The mean age of 20 patients was 27.25 ± 10.92 (range: 14–47 years) years, and of the patients, 18 (90%) were male and 2 (10%) were female. Six patients were hospitalized with recurrent pneumothorax, the number of relapses ranged from 1 to 4. The mean operative time was 48.50 ± 32.38 min. Almost no bleeding during the operation. No complications occurred in all patients during the perioperative period. The median follow-up was 19.70 ± 16.16 months. Only one patient was relapsed after multipoint pleura cautery 5 months later. He was hospitalized with the symptom of chest distress, and the right lung compressed by 30%. We can find the air was below the pleural cavity and the apical pleura which we performed pleurodesis was tightly adhered through the lung computed tomography [Figures 3 and 4]. This patient was discharged after 3 days of conservative treatment.

Figure 3

The air is located in the lower right lung pleural cavity

Figure 4

The tight symphysis between the visceral and parietal pleura in the upper right lung where we performed C-shaped pleura cautery

DISCUSSION

PSP mostly occurs in young, tall, thin males.[7] The current international guidelines only advocate surgical intervention at second occurrence or on ongoing/non-resolving air leak.[8910] However, thoracic surgeons being more likely to advocate management of first occurrence with surgical pleurodesis by reducing length of stay, as well as recurrence rate.[11] At present, pleurectomy and pleural abrasion are most commonly used in pneumothorax patients.[12] Nevertheless, the efficiency of pleural abrasion for pneumothorax patients has been questioned in recent years.[13] Pleurectomy versus pleural abrasion can reduce pneumothorax recurrence rates.[14] However, many surgeons refuse to use this technique just as the higher rate of post-operative complications, including bleedings and haematothorax with a need of reoperation.[15]

In clinical practice, a variety of sclerosants has been widely applied to prevent pneumothorax recurrence, including tetracycline and its derivatives, talc, bleomycin, autologous blood patches, iodopovidone, silver nitrate and quinacrine.[16171819] There was no statistical difference on the pneumothorax recurrence between mechanical pleural abrasion and chemical pleurodesis, and more complications occurred.[20]

We try to use the technique of burning the multipoint of parietal pleura to promote the pleurae adhesion. The mechanical injury of the pleura caused by cauterization is tightly adhered, and the multiple C-shaped rings formed by multipoint pleura cautery can also achieve the same effect of pleural pleurectomy. Furthermore, the lesion of surgery and post-operative complications of our surgical technique are much less than pleurectomy, and the operation is easier. Although this technique requires further investigation, it may be a useful method of pleurodesis.

CONCLUSIONS

Pneumothorax is a very common and recurrent disease. Existing surgical techniques can reduce the recurrence rate, but they are still not satisfactory. C-shaped pleura cautery is technically easy and provides secure fixation between the parietal pleura and the visceral pleura. Although this technique requires further investigation, it may be a useful method of pleurodesis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.