Management of Spontaneous Pneumothorax Sibu P. Saha, M.D., Jack E. Arrants, M.D., Annamaria Kosa, M.D., and William H. Lee, Jr., M.D. ABSTRACT Recurrence is the most common complication of spontaneous pneumothorax. Open thoracotomy with resection or obliteration of blebs and parietal pleurectomy provides the best protection against recurrence.Twentyseven consecutive patients underwent open thoracotomy for recurrent pneumothorax with no mortality and minimum morbidity and have remained free from recurrence.We believe that thoracotomy should be more widely used in the treatment of what is called spontaneous pneumothorax, since this treatment may remove the real cause of the disease.
o-called spontaneous pneumothorax in apparently healthy individuals is a relatively common occurrence. It is usually due to rupture of a subpleural bleb. Although the general methods of treatment for spontaneous pneumothorax have become standardized in recent years, controversy has existed regarding the place of thoracotomy. With pneumothorax of less than 25%treatment is generally nonoperative. However, for pneumothorax over 25%tube thoracostomy or needle aspiration has been preferred in management. If a patient has had a contralateral pneumothorax, is engaged in a hazardous occupation, lives in an isolated area, or has incurred a second episode on the ipsilateral side, open thoracotomy and pleurodesis are advised. Tension pneumothorax and bilateral pneumothorax require immediate catheter drainage with water-trap decompression. This report evaluates open thoracotomy in the management of patients with recurrent spontaneous pneumothorax.
Methods and Treatment A total of 67 patients representing 136 pneumothoraces seen at the Medical University of South Carolina Hospital were analyzed. All patients with known pulmonary tuberculosis, tumor, or trauma were excluded. There were 50 male and 17 female Fatients, a ratio of 3 to 1, and 43 white and 24 black patients, a ratio of 2 to 1 . The majority of patients were between 20 and 40 years of age. The right lung was involved in 88 instances and the left lung in 45. Bilateral simultaneous spontaneous pneumothorax was recorded in 3 patients. Two approaches to treatment were used in this group of patients: nonoperaFrom the Division of Thoracic and Cardiovascular Surgery, Medical University of South Carolina, Charleston, S.C. Presented at the Twenty-first Annual Meeting of the Southern Thoracic Surgical Association, Williamsburg, Va., Nov. 7-9, 1974. Address reprint requests to Dr. Saha, Division of Thoracic and Cardiovascular Surgery, Medical University of South Carolina, 80 Barre St., Charleston, S.C. 29401.
VOL. 19, NO. 5, MAY, 1975
56 1
SAHA ET AL. tive (observation, needle aspiration, Intracath thoracostomy, and tube thoracostomy) and operative (open thoracotomy). Nonoperative Group. Fifty-two of the 67 patients were managed without operation. Ten with pneumothorax of less than 20% were treated with bedrest alone, and 9 recovered within five to ten days. Needle aspiration was successful less than 30% of the time. Intracath thoracostomy was effective on 7 out of 9 occasions. Tube thoracostomy was the most useful procedure in achieving expansion of the collapsed lung. Operative Group. Fifteen patients in this group of 67 underwent open thoracotomy between 1963 and 1972. Since then 12 additional patients have undergone open thoracotomy for spontaneous pneumothorax. Therefore a total of 27 consecutive patients who had thoracotomy were reviewed. Previous ipsilateral pneumothorax was recorded in 22 patients (81%).Six patients had had a previous single ipsilateral pneumothorax (22%)and the other 16 had had two or more episodes (59%). Of 4 patients with previous contralateral pneumothorax (15%),2 had had thoracotomy for their episodes and 2 had subsequent contralateral spontaneous pneumothorax treated successfully with tube thoracostomy. Elective thoracotomy for prevention of recurrent pneumothorax was carried out for 14 patients, while 13 had operative intervention for persistent air leak or incomplete expansion of the lung. Two-thirds of the patients had blebs involving the apex of the upper lobe (Fig. 1) with the lung otherwise appearing normal at operation. A third of the patients had multiple blebs involving one or both lobes. Nineteen operations were performed for excision of blebs with partial parietal pleurectomy (Fig. 1B) or pleural abrasion or both. Three of the 19 patients underwent pleurectomy and resection of blebs, and the remaining 16 had bleb resection with pleural abrasion. In 1 patient with multiple tiny blebs, only pleural abrasion was done. This patient required reexploration and excision of blebs because of persistent air leak. Resection of visible blebs without pleurectomy
FIG. 1 . (A) Preoperative chest roentgenogram showing recurrent left pneumothorax. (B) Chest roentgenogramfollowing resection of blebs and partial parietal pleurectomy. 562
THE ANNALS OF THORACIC SURGERY
Management of Spmtaneous Pneumothorax
FIG. 2. (A) Preoperative chest roentgenogram showing recurrent right fmeumothorax. (B) Post-
operative chest roentgenogram showing expanded lung with autostaples (right upper lobe).
was carried out in 6 patients, and 1 of these continued to have air leak in the postoperative period. One patient had oversewing of blebs only. The use of an autostapler device* (Fig. 2) has simplified this operation. Instead of repeated clamping and suturing of the lung, several applications of the autostapler can avoid multiple needle holes in the lung and provide an airtight seal. This has made excision or obliteration of blebs technically safer and simpler in our hands. COMPLICATIONS
One intraoperative complication occurred, involving laceration of the subclavian artery. The patient required 3 units of blood to replace volume lost, and the artery was repaired without sequelae. There were 6 postoperative complications: 2 air leaks that persisted longer than four days (but subsequently sealed), 3 significant instances of atelectasis, and 1 large pleural effusion. There were no deaths, and the average hospital stay was twelve days. FOLLOW-UP
Nonoperative Group. Because of the indigent economic status and migratory habits of many of these individuals, follow-up examinations were possible in only 26 patients (50%)and ranged from 18 to 168 months. Eighteen patients havs been followed more than 24 months. Nine (50%)of this group have sustained a total of 25 episodes of pneumothorax. Six patients have had ipsilateral recurrence and 3 suffered contralateral recurrence. Six patients followed for less than 24 months have remained free from recurrences. T w o patients died from unrelated causes in less than a year of follow-up. Operative Group. Twenty-five of the 27 patients (93%)were followed from 3 to 90 months. There has been no episode of recurrent ipsilateral pneumothorax. However, 2 patients experienced contralateral recurrent pneumothorax. * U S . Surgical Corp., 919 Third Ave., New York, N.Y.
10022. VOL. 19, NO. 5, MAY, 1975
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SAHA ET AL.
Comment Spontaneous pneumothorax is usually caused by rupture of a subpleural bleb. It occurs most commonly in men in the third and fourth decades [lo, 113. The risk of a recurrent spontaneous pneumothorax after the initial episode has been reported as 10 to 60% [5, 61. Closed (tube) thoracostomy is the main therapeutic approach in the majority of patients [6,7,9]. It is a simple procedure and, if properly done, carries minimal risk. However, this mode of therapy fails to ameliorate the basic pathogenesis of the syndrome. Since 1906 many substances (silver nitrate, hypertonic glucose, talc, kaolin, blood) have been introduced into the pleural cavity to produce artificial pleurodesis [2,3, 111. Pleurodesis has been condemned by Gaensler [5] on the grounds that injection or insufflation of irritating substances is “useless, uncertain, or dangerous.” The most effective prophylaxis against recurrence is open thoracotomy [4,5, 8, 121 and pleurodesis, probably best achieved by partial pleurectomy and abrasion. A bilateral approach either through a median sternotomy [ 111 or separate thoracotomy incisions has been advocated by some authors. Baronofsky and co-workers [ 13 pointed out that subpleural blebs were found bilaterally in 25 of 26 patients who underwent bilateral thoracotomy for an initial unilateral spontaneous pneumothorax. In the light of our observation of a low incidence of bilateral involvement, this would appear unnecessary. Two-thirds of our patients had apical blebs. They were successfully treated with wedge resection and partial parietal pleurectomy. Pleurodesis is achieved better by parietal pleurectomy than by pleural abrasion or scarification [11. Parietal pleurectomy remains the treatment of choice for patients in whom local excision is not applicable either because resection of all the blebs would entail loss of an unjustifiably large amount of lung tissue or because no lesion can be found on the lung surface.
References 1. Baronofsky, I. D., Warden, H. G., Kaufman, J. L., Whately, J., and Hanner, J. M. Bilateral therapy for unilateral spontaneous pneumothorax. J Thorac Surg 34:3 10, 1957. 2. Bethune, N. Pleural poudrage: New technique for deliberate production of pleural adhesions as preliminary to lobectomy. J Thorac Surg 4:251, 1935. 3. B e r n a r d , E . , a n d Meyer, A. T r e a t m e n t o f non-tuberculous spontaneous pneumothorax. Dis Chest 19:64 1, 195 1. 4. Crosby, I. K., Fiallos, E. E., and Reed, W. A. Thoracotomy for pneumoth0rax.J Kansas Med SOC 73:340, 1972. 5. Gaensler, E. A. Parietal pleurectomy for recurrent spontaneous pneumothorax. Surg Gynecol Obstet 102:293, 1956. 6. Gobbel, W. A., Jr., Rhea, W. A., Jr., Nelson, I. A., and Daniel, R. A. Spontaneous pneumothorax. J Thorac Cardiouasc Surg 46:331, 1963. 7. Hyde, L. Benign spontaneous pneumothorax. Ann Intern Med 56:746, 1962. 8 . Langer, J., Rzepecki, W., Gorka, Z., Paluszkiewica, K., Wruk, M., and Pietrzyk, M. Thoracotomy in the treatment of so-called spontaneous pneumothorax. Polish MedJ 10: 934, 1971. 9. Levis, I. J. Spontaneous pneumothorax: An analysis of 170 episodes in 135 patients. Dis Chest 49529, 1966. 10. Ruckley, C. V., and McCormack, R. J. M. T h e management of spontaneous pneumothorax. Thorax 21: 139, 1966. 1 1 . Smith, W. A., and Rothwell, P. G. T h e treatment of spontaneous pneumothorax. Thorax 17:342, 1962. 12. Wilson, K. S. Spontaneous pneumothorax: A ten year study. MilitMed 135:95,1970. 564
T H E ANNALS OF THORACIC SURGERY
o-called spontaneous pneumothorax in apparently healthy individuals is a relatively common occurrence. It is usually due to rupture of a subpleural bleb. Although the general methods of treatment for spontaneous pneumothorax have become standardized in recent years, controversy has existed regarding the place of thoracotomy. With pneumothorax of less than 25%treatment is generally nonoperative. However, for pneumothorax over 25%tube thoracostomy or needle aspiration has been preferred in management. If a patient has had a contralateral pneumothorax, is engaged in a hazardous occupation, lives in an isolated area, or has incurred a second episode on the ipsilateral side, open thoracotomy and pleurodesis are advised. Tension pneumothorax and bilateral pneumothorax require immediate catheter drainage with water-trap decompression. This report evaluates open thoracotomy in the management of patients with recurrent spontaneous pneumothorax.
Methods and Treatment A total of 67 patients representing 136 pneumothoraces seen at the Medical University of South Carolina Hospital were analyzed. All patients with known pulmonary tuberculosis, tumor, or trauma were excluded. There were 50 male and 17 female Fatients, a ratio of 3 to 1, and 43 white and 24 black patients, a ratio of 2 to 1 . The majority of patients were between 20 and 40 years of age. The right lung was involved in 88 instances and the left lung in 45. Bilateral simultaneous spontaneous pneumothorax was recorded in 3 patients. Two approaches to treatment were used in this group of patients: nonoperaFrom the Division of Thoracic and Cardiovascular Surgery, Medical University of South Carolina, Charleston, S.C. Presented at the Twenty-first Annual Meeting of the Southern Thoracic Surgical Association, Williamsburg, Va., Nov. 7-9, 1974. Address reprint requests to Dr. Saha, Division of Thoracic and Cardiovascular Surgery, Medical University of South Carolina, 80 Barre St., Charleston, S.C. 29401.
VOL. 19, NO. 5, MAY, 1975
56 1
SAHA ET AL. tive (observation, needle aspiration, Intracath thoracostomy, and tube thoracostomy) and operative (open thoracotomy). Nonoperative Group. Fifty-two of the 67 patients were managed without operation. Ten with pneumothorax of less than 20% were treated with bedrest alone, and 9 recovered within five to ten days. Needle aspiration was successful less than 30% of the time. Intracath thoracostomy was effective on 7 out of 9 occasions. Tube thoracostomy was the most useful procedure in achieving expansion of the collapsed lung. Operative Group. Fifteen patients in this group of 67 underwent open thoracotomy between 1963 and 1972. Since then 12 additional patients have undergone open thoracotomy for spontaneous pneumothorax. Therefore a total of 27 consecutive patients who had thoracotomy were reviewed. Previous ipsilateral pneumothorax was recorded in 22 patients (81%).Six patients had had a previous single ipsilateral pneumothorax (22%)and the other 16 had had two or more episodes (59%). Of 4 patients with previous contralateral pneumothorax (15%),2 had had thoracotomy for their episodes and 2 had subsequent contralateral spontaneous pneumothorax treated successfully with tube thoracostomy. Elective thoracotomy for prevention of recurrent pneumothorax was carried out for 14 patients, while 13 had operative intervention for persistent air leak or incomplete expansion of the lung. Two-thirds of the patients had blebs involving the apex of the upper lobe (Fig. 1) with the lung otherwise appearing normal at operation. A third of the patients had multiple blebs involving one or both lobes. Nineteen operations were performed for excision of blebs with partial parietal pleurectomy (Fig. 1B) or pleural abrasion or both. Three of the 19 patients underwent pleurectomy and resection of blebs, and the remaining 16 had bleb resection with pleural abrasion. In 1 patient with multiple tiny blebs, only pleural abrasion was done. This patient required reexploration and excision of blebs because of persistent air leak. Resection of visible blebs without pleurectomy
FIG. 1 . (A) Preoperative chest roentgenogram showing recurrent left pneumothorax. (B) Chest roentgenogramfollowing resection of blebs and partial parietal pleurectomy. 562
THE ANNALS OF THORACIC SURGERY
Management of Spmtaneous Pneumothorax
FIG. 2. (A) Preoperative chest roentgenogram showing recurrent right fmeumothorax. (B) Post-
operative chest roentgenogram showing expanded lung with autostaples (right upper lobe).
was carried out in 6 patients, and 1 of these continued to have air leak in the postoperative period. One patient had oversewing of blebs only. The use of an autostapler device* (Fig. 2) has simplified this operation. Instead of repeated clamping and suturing of the lung, several applications of the autostapler can avoid multiple needle holes in the lung and provide an airtight seal. This has made excision or obliteration of blebs technically safer and simpler in our hands. COMPLICATIONS
One intraoperative complication occurred, involving laceration of the subclavian artery. The patient required 3 units of blood to replace volume lost, and the artery was repaired without sequelae. There were 6 postoperative complications: 2 air leaks that persisted longer than four days (but subsequently sealed), 3 significant instances of atelectasis, and 1 large pleural effusion. There were no deaths, and the average hospital stay was twelve days. FOLLOW-UP
Nonoperative Group. Because of the indigent economic status and migratory habits of many of these individuals, follow-up examinations were possible in only 26 patients (50%)and ranged from 18 to 168 months. Eighteen patients havs been followed more than 24 months. Nine (50%)of this group have sustained a total of 25 episodes of pneumothorax. Six patients have had ipsilateral recurrence and 3 suffered contralateral recurrence. Six patients followed for less than 24 months have remained free from recurrences. T w o patients died from unrelated causes in less than a year of follow-up. Operative Group. Twenty-five of the 27 patients (93%)were followed from 3 to 90 months. There has been no episode of recurrent ipsilateral pneumothorax. However, 2 patients experienced contralateral recurrent pneumothorax. * U S . Surgical Corp., 919 Third Ave., New York, N.Y.
10022. VOL. 19, NO. 5, MAY, 1975
563
SAHA ET AL.
Comment Spontaneous pneumothorax is usually caused by rupture of a subpleural bleb. It occurs most commonly in men in the third and fourth decades [lo, 113. The risk of a recurrent spontaneous pneumothorax after the initial episode has been reported as 10 to 60% [5, 61. Closed (tube) thoracostomy is the main therapeutic approach in the majority of patients [6,7,9]. It is a simple procedure and, if properly done, carries minimal risk. However, this mode of therapy fails to ameliorate the basic pathogenesis of the syndrome. Since 1906 many substances (silver nitrate, hypertonic glucose, talc, kaolin, blood) have been introduced into the pleural cavity to produce artificial pleurodesis [2,3, 111. Pleurodesis has been condemned by Gaensler [5] on the grounds that injection or insufflation of irritating substances is “useless, uncertain, or dangerous.” The most effective prophylaxis against recurrence is open thoracotomy [4,5, 8, 121 and pleurodesis, probably best achieved by partial pleurectomy and abrasion. A bilateral approach either through a median sternotomy [ 111 or separate thoracotomy incisions has been advocated by some authors. Baronofsky and co-workers [ 13 pointed out that subpleural blebs were found bilaterally in 25 of 26 patients who underwent bilateral thoracotomy for an initial unilateral spontaneous pneumothorax. In the light of our observation of a low incidence of bilateral involvement, this would appear unnecessary. Two-thirds of our patients had apical blebs. They were successfully treated with wedge resection and partial parietal pleurectomy. Pleurodesis is achieved better by parietal pleurectomy than by pleural abrasion or scarification [11. Parietal pleurectomy remains the treatment of choice for patients in whom local excision is not applicable either because resection of all the blebs would entail loss of an unjustifiably large amount of lung tissue or because no lesion can be found on the lung surface.
References 1. Baronofsky, I. D., Warden, H. G., Kaufman, J. L., Whately, J., and Hanner, J. M. Bilateral therapy for unilateral spontaneous pneumothorax. J Thorac Surg 34:3 10, 1957. 2. Bethune, N. Pleural poudrage: New technique for deliberate production of pleural adhesions as preliminary to lobectomy. J Thorac Surg 4:251, 1935. 3. B e r n a r d , E . , a n d Meyer, A. T r e a t m e n t o f non-tuberculous spontaneous pneumothorax. Dis Chest 19:64 1, 195 1. 4. Crosby, I. K., Fiallos, E. E., and Reed, W. A. Thoracotomy for pneumoth0rax.J Kansas Med SOC 73:340, 1972. 5. Gaensler, E. A. Parietal pleurectomy for recurrent spontaneous pneumothorax. Surg Gynecol Obstet 102:293, 1956. 6. Gobbel, W. A., Jr., Rhea, W. A., Jr., Nelson, I. A., and Daniel, R. A. Spontaneous pneumothorax. J Thorac Cardiouasc Surg 46:331, 1963. 7. Hyde, L. Benign spontaneous pneumothorax. Ann Intern Med 56:746, 1962. 8 . Langer, J., Rzepecki, W., Gorka, Z., Paluszkiewica, K., Wruk, M., and Pietrzyk, M. Thoracotomy in the treatment of so-called spontaneous pneumothorax. Polish MedJ 10: 934, 1971. 9. Levis, I. J. Spontaneous pneumothorax: An analysis of 170 episodes in 135 patients. Dis Chest 49529, 1966. 10. Ruckley, C. V., and McCormack, R. J. M. T h e management of spontaneous pneumothorax. Thorax 21: 139, 1966. 1 1 . Smith, W. A., and Rothwell, P. G. T h e treatment of spontaneous pneumothorax. Thorax 17:342, 1962. 12. Wilson, K. S. Spontaneous pneumothorax: A ten year study. MilitMed 135:95,1970. 564
T H E ANNALS OF THORACIC SURGERY
