Methods: Between January 2009 and December 2015, a total of 199 patients (178 males, 21 females; mean age 21.3±7.1 years; range 13 to 35 years) with primary spontaneous pneumothorax who were operated at Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Thoracic Surgery and Kadikoy and Kozyatagi Acibadem hospitals were retrospectively analyzed. Of these patients, 48 underwent axillary thoracotomy, wedge resection, apical pleurectomy, and tissue adhesives, while 151 were administered videoassisted thoracoscopic surgery, wedge resection, apical pleurectomy, and tissue adhesives. Both groups were compared in terms of age, gender, the amount of long-term analgesic use, duration of surgery, length of hospitalization, recurrence, complication, and mortality rates.
Results: The patients were followed for one year. No mortality was observed in any patient. There was no significant difference in the age and gender distributions of the patients, postoperative length of hospital stay, recurrence rates, and complication rates according to the type of operation. However, the duration of operation was longer in the videoassisted thoracoscopic surgery patients.
Conclusion: Video-assisted thoracoscopic surgery is associated with less pain and higher patient satisfaction and allows returning to daily activities in a shorter time period. Based on our study results, we suggest that video-assisted thoracoscopic surgery is more suitable, compared to axillary thoracotomy, owing to its advantages, such as being less invasive and providing a better angle of view.
The incidence of pneumothorax in men and women has been reported as 24 and 9.8, respectively, per 100,000.[5] On the other hand, the incidence of primary spontaneous pneumothorax is 7.4 to 18 per 100,000 men and 1.2 to 6 per 100,000 women.[6,7] Treatment options for spontaneous pneumothorax include conservative approaches from bed rest, to more invasive procedures such as aspiration and chest tube drainage, chemical pleurodesis, and surgical procedures such as video-assisted thoracoscopic surgery (VATS) or axillary thoracotomy. The recurrence rate following conservative treatment after the first attack of spontaneous pneumothorax is estimated to be between 30% and 50%.[8] The most commonly accepted indications for surgical treatment of spontaneous pneumothorax include; prolonged air leak (more than seven days long), recurrent pneumothorax, contralateral pneumothorax and patients in high risk occupational groups (such as pilots and divers) with the first spontaneous pneumothorax.[2,9,10] The conventional treatment method of spontaneous pneumothorax is open axillary thoracotomy with bullectomy and pleurectomy. Bullae resection and the use of VATS during partial pleurectomy for the treatment of pneumothorax was first described in 1991.[11] In this study, the advantages and disadvantages of axillary thoracotomy and VATS, and their superiority over each other were evaluated.
The Number Cruncher Statistical System (NCSS) 2007 & Power Analysis and Sample Size (PASS) 2008 Statistical Software (Utah, USA) used for statistical analysis. Descriptive statistical methods (Mean, Standard Deviation, Median, Frequency, Ratio, Minimum, and Maximum) were used for the evaluation of study data, while the Mann-Whitney U test was used for the comparison of quantitative data as well as parameters without normal distribution for the two groups. The Fisher's exact test was used for the comparison of qualitative data. The level of significance was evaluated at p<0.01 and p<0.05 values.
Table 1: Distribution of descriptive characteristics
Wedge resection together with apical pleurectomy
and tissue adhesion were performed in both video assisted thoracoscopic surgery and axillary
thoracotomy procedures. Five of the patients
underwent bilateral surgery at different times due to
contralateral recurrent pneumothorax. Fifty-four of
the patients were those who had pneumothorax for
the first time, underwent tube thoracostomy + closed
underwater drainage, and who were considered to
have prolonged air leak (PAL) due to air leakage
of more than five days during the follow-up period
and subjected to surgery. The remaining surgical
procedures were performed on 145 patients (119 with
recurrence for the first time, 16 with recurrence for
the second time, six with recurrence for the third
time, two with fourth recurrence, and two with fifth
recurrence), who were previously treated with oxygen
therapy or who were subjected to surgery following
recurrence after being treated with tube thoracostomy.
Our surgical interventions resulted in a total of nine
recurrences (four axillary thoracotomy, and five
VATS procedures). All of these nine recurrence cases
were subjected to reoperation (three with thoracotomy
and six with VATS).
The evaluations made according to the type of
surgery are shown in the last row of Table 1 and
in Table 2. The mean postoperative hospital stay
was found to be 5.1±2.6 (range: 2-20) days. The
postoperative hospital stay was calculated as 4.6±1.7
days (range 2 to 12) days in the axillary thoracotomy
group, and 5.5±3.0 (range, 2 to 20) days in the
VATS group, just slightly more than in the axillary
thoracotomy group. In the axillary thoracotomy
group, there were 41 males (85.4%) and seven females
(14.9%), whereas in the VATS group there were 137
males (90.7%) and 14 females (9.3%). The number
of cases of recurrences in the axillary thoracotomy
group was found to be four (8.3%), and that in the
VATS group was found to be four (2.64%). On the
other hand, with regards to complications, prolonged
air leakage was observed in six patients (12.5%)
subjected to axillary thoracotomy, and in 12 patients
(7.9%) who underwent the VATS procedure.
Table 2: Evaluation according to type of surgery
There was no statistically significant difference
between age distribution, postoperative hospital
stay, gender distribution, recurrence rates and rate
complication according to surgical type (p>0.05).
The duration of surgery in our study was found to
be longer in the VATS group, with the mean duration in
the axillary thoracotomy Group reported as 40±10 min
and in the VATS Group as 65±15 min. The rate of
long-term analgesic use in our study was reported as
4% in VATS patients and 25% in axillary thoracotomy
patients. No infection and bleeding requiring revision was observed in any patient, and no mortality was
reported.
In the study by Kocatürk et al.,[13] the most common surgical indications for primary spontaneous pneumothorax was reported as ipsilateral recurrent pneumothorax and prolonged air leak (PAL). Similar incidence rates were observed in our study.
Following a wedge resection, pleural adhesion is provided by a combination of pleurectomy, pleural abrasion or chemical irritation procedures. Pleurectomy is suggested to be better in terms of recurrence when compared to pleural abrasion.[14-17]
The combination of bullectomy and parietal pleurectomy is an effective method to prevent the recurrence of pneumothorax. However, parietal pleurectomy has its drawbacks; especially in young patients, serious problems may be encountered when the pleura is opened in the future due to any cause like lung transplantation. As a result, alternative partial pleurectomy or parietal abrasion techniques are currently being used for pleurodesis.[3,18] Bullae and blebs are mostly found at the apex of the lungs. Horio et al.[19] demonstrated that recurrence rates were higher in patients treated with VATS than in those who underwent thoracotomy. This was suggested to be due to the fact that there was a higher likelihood of bullae or blebs being missed in the VATS group of patients. Technically, it is more difficult to test air leak during VATS than during open surgery. Many authors recommend wedge resection of the apex of the lung because it is important not only to remove blebs in all cases, but also for the formation of inflammation in the lungs and thoracic walls, even when bullae cannot be observed at the apex.[20,21]
The ipsilateral recurrence rate in patients treated with non-surgical methods is reported to range widely from 16% to 52%. On the other hand, the contralateral recurrence rate was reported as 5-15%. The value of CT for the recurrence of pneumothorax has previously been demonstrated by various studies.[22-26] In our study, all patients were subjected to CT before treatment. In a meta-analysis involving studies conducted between 1993 and 2006, recurrence rates ranged from 0% to 16% for VATS and from 0% to 6.8% for open surgical procedures.[27] The American College of Chest Physicians (ACCP) recommends thoracoscopic surgery for the prevention of recurrence,[10] whereas the British Thoracic Society (BTS) recommends open surgery and pleurectomy due to the low recurrence rate.[28]
In our study, the recurrence rate following axillary thoracotomy was 8.3% (n=4), while the recurrence rate after VATS was found to be 2.6% (n=4). This rate was higher in cases with axillary thoracotomy, although not statistically significant. Unlike the results of our study, the majority of the studies have demonstrated that the recurrence rate is higher in the VATS group.[27]
Literature studies confirm that the duration of hospitalization and postoperative pain are reduced in patients treated with VATS when compared to thoracotomy.[29-32] In t he study conducted by Tarshihi, the duration of surgery in patients treated with VATS was reported as 78.9±6.2 min, whereas that for axillary thoracotomy was found to be 28.8±4.2 min.[33] These results were found to be consistent with the duration of the surgery in our study. We suggest that the longer the duration of video assisted thoracoscopic surgical interventions is as a result of the learning curve. This was observed as the duration of the last VATS attempts were shorter in recent years.
Video assisted thoracoscopic surgical techniques have advantages such as less pain, shorter time of return to normal activities, less chronic pain and better patient satisfaction. Literature studies show that chronic pain requiring analgesic use for longer than one month was at a rate of 3% after VATS and 19% after open surgery.[34] In our study, the rate long-term analgesic use was 4% for patients subjected to VATS and 25% for axillary thoracotomy patients.
No postoperative complications were observed in our study except for PAL. The absence of other complications such as pneumonia, arrhythmia, atelectasis, are attributed to the fact that patients were young and had no comorbid diseases; and there was no statistically significant difference between the two groups.
Surgery for primary spontaneous pneumothorax is generally safe and the surgery related mortality rate is not reported in many studies.[35,36] No case of mortality was also reported in our study. However, it should be kept in mind that mortality due to surgery for secondary spontaneous pneumothorax is between 2-10%.[28,37]
We suggest that VATS is the primary treatment option in the surgical treatment of primary spontaneous pneumothorax when compared to axillary thoracotomy, due to the decreased need for analgesia, shorter duration of hospitalization and faster mobilization, although there is no statistically significant difference in results between the video-thoracoscopic surgery group and axillary thoracotomy group.
Declaration of conflicting interests
The authors declared no conflicts of interest with respect to
the authorship and/or publication of this article.
Funding
The authors received no financial support for the research
and/or authorship of this article.
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