Video-assisted thoracoscopic treatment of spontaneous pneumothorax: technique and results of one hundred cases

OBJECTIVE: This article describes the technique and results for an initial series of 100 pneumothoraces treated by video-assisted thoracoscopy. METHODS: From May 1991 to November 1994, 97 patients (78 male and 19 female patients) aged 37.2 +/- 17 years (range 14 to 92 years) underwent video-assisted thoracoscopy for treatment of spontaneous pneumothorax (primary in 75 patients, secondary in 22 patients). RESULTS: The procedure was unilateral in 94 patients and bilateral in three patients (total 100 cases). Pleural bullae were resected with an endoscopic linear stapler; a lung biopsy was performed in the absence of any identifiable lesion. Pleurodesis was achieved by electrocoagulation of the pleura (n = 3), "patch" pleurectomy (n = 3), subtotal pleurectomy (n = 20), or pleural abrasion (n = 74), including conversion to standard thoracotomy in five. One of these five patients had primary pneumothorax and four had secondary pneumothorax. There were no postoperative deaths. A complication developed in 10 patients: five patients with a primary pneumothorax (6.6%) and five with a secondary pneumothorax (27.7%). The mean postoperative hospital stay was 8.25 +/- 3.2 days. Mean follow-up is 30 months (range 7 to 49 months). Pneumothorax recurred in 3% of patients, all of whom were operated on at the start of our experience. Three percent of the patients had chronic postoperative chest pain. CONCLUSIONS: Video-assisted thoracoscopy is a valid alternative to open thoracotomy for the treatment of spontaneous primary pneumothorax. Its role for the management of secondary pneumothorax remains to be defined. In the long term, the efficacy of video-assisted thoracoscopic pleurodesis and surgeon experience should yield the same results as standard operative therapy.     

Intraoperative delayed pneumothorax after subclavian vein catheterization

Intraoperative delayed pneumothorax occurred in five patients. It took several attempts to insert a subclavian vein catheter in four of the patients. The first chest X-ray films after the insertion of the catheter in the five patients were not indicative of pneumothorax. Pulse oximetry could detect the initial sign of pneumothorax prior to hemodynamic instability in three patients. In case of positive pressure ventilation and nitrous oxide administration for general anesthesia, this complication may be life threatening. It is necessary to take great care not to overlook intraoperative delayed pneumothorax in a patient with subclavian vein catheterization.     

Case report: pneumomediastinum and pneumothorax complicating colonoscopy

Colonic perforation is potentially the most serious complication of colonoscopy. Both the clinical manifestation and rapidity of onset of symptoms can vary depending on whether the perforation occurs directly into the peritoneal cavity or into the retroperitoneal space. Colonic perforation is often associated with abdominal pain, although more uncommon presentations have been documented. A case report of a unilateral pneumothorax and pneumomediastinum complicating colonoscopy is described, which responded well to conservative measures without recourse to surgical intervention, antibiotic therapy or parenteral alimentation.     

Pneumothorax: an unusual cause of ICD defibrillation failure

We describe two patients with defibrillation failure of implantable cardioverter defibrillators (ICDs) resulting from large left pneumothoraxes following subclavian vein puncture during the implantation. Following pneumothorax drainage, low defibrillation thresholds (DFTs) were attained without further manipulations. The absence of other signs and symptoms of pneumothorax and the presence of satisfactory pacing function during the procedure, resulted in a significant delay in diagnosis. Pneumothorax should be included in the differential diagnosis when unexpected high DFTs are found during ICD implantation or predischarge testing. This complication is avoidable by a different surgical approach, cephalic vein cutdown.     

Treatment of patients with spontaneous pneumothorax during videothoracoscopy

Thoracoscopy for spontaneous pneumothorax has been performed over the years by many pulmonologists. The aim of the procedure was merely diagnostic: the detection of blebs and bullae. Therapeutic modalities were restricted to chemical pleurodesis. The development of videothoracoscopy has made more complex interventions, such as bullectomy possible. A protocol for videothoracoscopic treatment of spontaneous pneumothorax, with all treatment modalities in one session, has been developed. All patients with spontaneous pneumothorax underwent videothoracoscopy under general anaesthesia with double lumen tube intubation. If no abnormalities were found on the visceral pleura, talc pleurodesis was performed. Small lesions, blebs or bullae < 2 cm, were coagulated prior to pleurodesis. In case of blebs or bullae > 2 cm, thoracoscopic resection with an EndoGIA stapling device was performed, followed by scarification, i.e. electrocoagulation, of the parietal pleura. In 43 patients, 44 procedures were performed. In 15 cases (34%) no blebs or bullae were found. In 6 cases (14%) only blebs < 2 cm were found. In 23 cases (52%) blebs and bullae > 2 cm were found. In 21 out of 44 cases (48%), talc pleurodesis was performed, and in 23 cases (52%) bullectomy was performed. No major complication occurred. The average hospital stay was 5.7 days after talc pleurodesis and 6.0 days after bullectomy. There were 2 recurrences (5%) after a follow-up of at least 18 months. In conclusion, the use of videothoracoscopy in spontaneous pneumothorax makes it possible to continue a diagnostic procedure as a therapeutic session.(ABSTRACT TRUNCATED AT 250 WORDS)     

Complications of laparoscopic pelvic surgery: recognition, management and prevention

Laparoscopic surgery has many advantages but it is not without complications. The complexity of the surgery significantly influences the complication rate. Laparoscopic surgeons ought to be aware of the possible complications and how they could be prevented, recognized without delay, and managed safely and efficiently. Important complications include injuries to the vessels, bowel and urinary tract. Incisional hernia ought to be reduced by careful closure of the fascia whenever a trocar > or =10 mm is used at the extraumbilical site. Gas embolism is a rare but potentially life threatening complication. Shoulder pain is a minor complication but is exceedingly common; it is less likely to occur if as much gas as possible is removed at the end of the operation while the patient is still in head down Trendelenburg position. Rare complications include pneumothorax, subcutaneous and pre-peritoneal emphysema, cardiac arrhythmia, nerve injury and venous thrombosis. Laparoscopic surgeons should also understand the principles of electrosurgery and how to avoid complications arising from the use of electrical energy including capacitative coupling, direct coupling and insulation failure.     

Pleural disease and acquired immune deficiency syndrome

Patients with acquired immune deficiency syndrome (AIDS) do not frequently have pleural complications. However, pneumothorax is a troublesome complication of patients with AIDS. At some medical centres, more than 50% of patients with spontaneous pneumothorax have AIDS. Most patients with spontaneous pneumothorax and AIDS have Pneumocystis carinii infection and necrotic subpleural blebs. The pneumothoraces in these patients usually cannot be managed with tube thoracostomy alone. Patients who do not respond to tube thoracostomy are best managed with a Heimlich valve or with thoracostomy with stapling of blebs and pleural abrasion. Approximately 2% of human immunodeficiency virus (HIV)-positive individuals will have a pleural effusion. Parapneumonic effusions or empyema, tuberculosis and Kaposi's sarcoma are the three leading causes. P. carinii infection is frequently responsible for pulmonary infections, but is only occasionally responsible for a pleural effusion. Pleural effusions may also develop from non-Hodgkin's lymphoma (NHL). There is one relatively rare NHL that is associated with the Kaposi's sarcoma associated virus that produces a lymphoma confined to the body cavity.     

Complication rates of tube thoracostomy

This study compared the complication rates of tube thoracostomy performed in the emergency department (ED) versus the operating room (OR) and the inpatient ward (IW). A retrospective case series of all patients at an urban, university-based level 1 trauma center hospital who received tube thoracostomy for any indication between 1/1/93 and 12/31/93 was conducted. Complications were defined as empyema, unresolved pneumothorax (persistent air leak or residual pneumothorax), persistent effusion, or incorrect placement. The data for age and duration of tube placement were weighted for analysis of variance (ANOVA). A total of 352 tube thoracostomies was placed in 239 patients. Twenty-three patients had three or more chest tubes placed, 65 had two placed, and the remaining 181 had a single tube. Ninety-nine tubes were placed in the ED, 87 in the OR, and 166 on IW. The mean age of patients in the ED was 37 years, and differed significantly (P < .015) from those in the OR (48 years) and the IW (44 years). The duration of tube placement was similar for all groups (mean = 6.5 days). The overall complication rates related to tube insertion were: ED, 14.0%; OR, 9.2%; IW, 25.3%. Significance was achieved when comparing complication rates between the ED and IW, with less complications in the ED (P = .0436). When comparing complication rates between the ED and OR, there was no significant difference (P = .3643). A power calculation indicated too small of a sample size to truly determine an insignificant difference between complication rates between the ED and OR. Placement of emergent thoracostomy tubes in the ED does not result in an increased complication rate as compared to placement in the IW.     

Dermatomyositis with subclinical myositis and spontaneous pneumomediastinum with pneumothorax: case report and review of the literature

Dermatomyositis (DM) is a clinical entity characterized by a distinctive cutaneous rash and inflammatory myopathy. Besides skin and muscle, the disease can also involve other internal organs, especially the lungs. We describe a patient with dermatomyositis and incomplete signs of myositis who developed pneumomediastinum, pneumothorax and massive subcutaneous emphysema. This case illustrates a rare pulmonary complication of DM, and underscores that muscular involvement in this disease is not always reflected in laboratory and/or histological abnormalities.     

Axillary vein puncture over the second rib

BACKGROUND: Video-assisted thoracic operations usually require single-lung ventilation under general anesthesia. However, for high-risk patients with other underlying pulmonary diseases, one has to consider risks of general anesthesia itself. METHODS: Four high-risk patients (4 men; mean age, 73 years) with intractable secondary pneumothorax and other underlying pulmonary diseases were treated by video-assisted thoracic operations under local and epidural anesthesia. Absorbable polyglycolic acid sheets and fibrin glue were used to control the air leakage. RESULTS: The mean duration of the procedure was 108 minutes. Pain and cough reflex were well controlled, and spontaneous breathing and hemodynamics were well maintained during the operation. The mean duration of the postoperative chest drainage was 5 days. No significant postoperative complication was encountered. No pneumothorax had recurred at a mean follow-up of 16 months. CONCLUSIONS: Video-assisted thoracic operations can be performed safely under local and epidural anesthesia for the treatment of intractable secondary pneumothorax in high-risk patients. The air leakage can be controlled with the use of polyglycolic acid sheets and fibrin glue without bullectomy.     

Limited axillary thoracotomy vs video-assisted thoracoscopic surgery for spontaneous pneumothorax

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) has been reported to have a higher pneumothorax recurrence rate than limited axillary thoracotomy (LAT). We investigated the cause of pneumothorax recurrence after VATS by comparing surgical results for VATS and LAT. METHODS: Ninety-five patients with spontaneous pneumothorax underwent resection of pulmonary bullae by VATS (n = 51) or LAT (n = 44). Operating duration, bleeding during surgery, number of resected bullae, duration of postoperative chest tube drainage, postoperative hospital stay, postoperative complication, and pneumothorax recurrence were analyzed to compare VATS and LAT in a retrospective study. RESULTS: The duration of surgery, postoperative chest tube drainage, and postoperative hospital stay was significantly shorter in VATS than in LAT cases (p < 0.0005 and p < 0.005). Bleeding during surgery was significantly less in VATS than in LAT cases (p < 0.005). Numbers of resected bullae were significantly lower in VATS (2.7 +/- 2.1) than in LAT cases (3.9 +/- 2.7) (p < 0.05). Postoperative pneumothorax recurrence was more frequent in VATS (13.7%) than in LAT cases (6.8%), but there was no significant difference. CONCLUSIONS: VATS has many advantages over LAT in treating spontaneous pneumothorax, although the pneumothorax recurrence rate in VATS cases was double that in LAT cases. The lower number of resected bullae in VATS than in LAT cases suggests that overlooking bullae in operation could be responsible for the high recurrence rate in VATS cases. We recommend additional pleurodesis in VATS for spontaneous pneumothorax to prevent postoperative pneumothorax recurrence.     

Video-assisted thoracic surgery in patients with spontaneous pneumothorax

Following the development of video-assisted technologies and the principle of minimally-invasive surgery thoracoscopy has finally established itself as an integral part of the surgeon's armamentarium in the treatment of spontaneous pneumothorax. This procedure was performed on 18 patients at the Department of Cardio-Thoracic Surgery of the Medical University in Vienna from October 1995 to April 1996 and on 5 patients at the Department of Thoraco-Abdominal Surgery of the Medical University in Plovdiv from October 1996 to January 1997, all of which had been diagnosed as having complicated spontaneous pneumothorax. The main indications were: recurrent spontaneous pneumothorax or persistent pneumothorax following a five-day unsuccessful drainage of the pleural cavity. All our patients underwent partial parietal pleurectomy down to the level of the third intercostal space. Apical blebs were found in 14 patients and atypical wedge resection was performed. The authors used three trocars 5-12 mm in diameter. The thoracoscope was inserted in the fifth intercostal space in the midaxillary line. The other two operative trocars were inserted in the anterior and posterior axillary lines, respectively. The mean postoperative stay was 6 days. Our results support the view that video-assisted thoracic surgery is technically feasible and safe, associated with decreased perioperative pain and opiate requirements, shorter hospital stay, excellent cosmetic results, low recurrence rate, early return to routine activity and minimal morbidity and is therefore superior to conventional thoracotomy.     

Pneumothorax in AIDS: case reviews and proposed clinical management

BACKGROUND: Pneumothorax is a not uncommon complication of advanced HIV infection, and may prove difficult to manage in view of its recalcitrant and recurrent nature. In this group where immunosuppression and reduced life expectancy are a feature, standard protocols are often abandoned in favour of a more conservative approach. This is often unsuccessful. METHODS: Patients attending the Department of Genitourinary Medicine, Chelsea and Westminster Hospital who sustained pneumothorax between 1988 and 1992 were identified retrospectively and their notes reviewed. RESULTS: Fifteen patients were identified of whom three had post-procedural pneumothoraces. In the remaining 12 patients, 10 had previously had Pneumocystic carinii pneumonia (PCP), whilst all 12 had some evidence to suggest current PCP (seven proven, five presumptive). In those six patients with a single, unilateral pneumothorax, four were managed successfully with intercostal drainage alone (one patient died early, one required pleurectomy). In those with recurrent pneumothoraces or pneumothoraces that did not respond to prolonged intercostal drainage, failure of medical treatment was judged to have occurred and surgery was performed. Overall, conservative management failed in 7/11 patients. Conversely surgery resulted in resolution in 7/7 with recurrence seen in one individual. Median survival was similar in the two groups. CONCLUSIONS: Pneumothorax in patients with AIDS is associated with a high rate of intercurrent PCP; a low threshold for treating this infection presumptively is indicated. Intercostal drainage was successful in patients with a single, unilateral pneumothorax. However, in patients with recurrent or bilateral pneumothorax extended periods on intercostal drainage were uniformly unsuccessful. Early surgical referral should be considered in this group.     

Meta-analysis of the efficacy of extradural clonidine to relieve postoperative pain: an impossible task

PURPOSE: The diagnostic accuracy and rate of complications of CT-guided core biopsies (CB) from suspected tumors of the chest were compared to the accuracy a complications of fine-needle aspiration biopsies (FNAB). METHODS: The accuracy in the diagnosis of a benign or malignant lesion of 79 FNAB (19.5 G self-aspirating cutting needle) and of 83 CB (18 G automated core biopsy) and the rates of pneumothorax, pleural drainage and hemoptysis were retrospectively evaluated. RESULTS: With FNAB, the sensitivity for malignant lesions was 62.1% and the accuracy 68.4%. With CB the sensitivity amounted to 85.9% and accuracy to 86.7%. The rate of pneumothorax was 25.3% following FNAB, with a drainage rate of 5.1% compared to 19.3% and 6.0%, respectively, following CB. The rate of pneumothorax and drainage increased with increasing path length through aerated lung. In advanced emphysema, the pneumothorax rate did not increase; however, in pneumothoraces, pleural drainage was mandatory in 20% of FNAB and in 100% of CB. Hemoptysis without any therapeutic consequences occurred in 3.8% following FNAB and in 6.0% following CB. CONCLUSIONS: With CB diagnostic accuracy can be clearly increased without an obvious increase in the complication rate. However, in patients with obvious emphysema, the pleural drainage rate of pneumothorax may be higher following CB.     

A case of bilateral pneumothorax successfully treated with surgery associated with amyotrophic lateral sclerosis having been controlled with artificial ventilation]

We reported a case of bilateral pneumothorax, which was successfully treated with surgery, associated with amyotrophic lateral sclerosis (ALS). The patient had been controlled with artificial ventilation at the time of surgery. Prognosis of ALS is absolutely poor, and the life expectancies for patients with ALS are presumed several years, even though they are controlled with artificial ventilation. We applied a surgical treatment for a patient with ALS who developed bilateral pneumothorax as a life saving procedure.     

Successful treatment of liver hemorrhage in the premature infant

BACKGROUND: The efficacy of tube thoracostomies inserted at the sixth intercostal space at midaxillary line was evaluated retrospectively in children. METHODS: Ninety-seven children with pneumothorax, treated by tube thoracostomy were taken into the study. There were 67 male and 30 female patients with a mean age of 6.5 years (range 1 days to 15 years) RESULTS: Pneumothorax was located at the right side in 50 (51.5%), and at the left in 38 (39.1%) of the cases. Bilateral pneumothorax was found in 9 additional patients (9.2%). All patients were treated with tube thoracostomy placed in the pleural cavity at the sixth intercostal space at the mid-axillary line. Postoperative course was uneventful and no complication was encountered at any of the patients. CONCLUSIONS: On the basis of these data we suggest that all thoracostomy tubes should be inserted on the sixth intercostal space where both air and the accumulating fluid can be reached. The insertion of the thoracostomy tube at the second intercostal space must be avoided since it carries a high risk of subclavian vein injury in small children, and also a secondary tube is frequently required to drain the accompanying intrapleural fluid.     

Fournier's gangrene: a clinical presentation of necrotizing fasciitis after bone marrow transplantation

Three patients with ANLL developed Fournier's gangrene as an early complication after allo-BMT (two cases) and auto-BMT (one case); two patients were in first CR, the third had resistant disease. Patients developed fever, perineal pain, swelling and blistering of the genital area. Pseudomonas aeruginosa was isolated from the lesions and patients received systemic antibiotic therapy, surgical debridement and medication with potassium permanganate solution. Two patients made a complete recovery although one died of sepsis. The third had progressive involvement of the abdominal wall and later died of leukemia. Early diagnosis of this disorder and prompt initiation of appropriate therapy can prevent progression of this acute necrotizing infection.     

Osteonecrosis after contact neodymium:yttrium aluminum garnet arthroscopic laser meniscectomy

OBJECTIVE: The purpose of this report is to describe two cases of osteonecrosis that occurred after arthroscopic meniscectomy with a contact neodymium:yttrium aluminum garnet laser system. The patients developed increasing knee pain and disability 5 months and 6 months after laser meniscectomy. MR imaging showed subchondral osteonecrosis in the femoral condyle and tibial plateau immediately adjacent to the site of laser meniscectomy in both patients. One patient required a total knee replacement to alleviate knee symptoms, and the other patient required a tibial osteotomy and surgical elevation of collapsed tibial articular surface. CONCLUSION: To our knowledge, this complication of laser arthroscopic meniscectomy has not been reported in the radiology literature. The clinical and MR imaging features of this important complication are described and possible causative mechanisms are discussed.     

Rescue echocardiographically guided pericardiocentesis for cardiac perforation complicating catheter-based procedures. The Mayo Clinic experience

OBJECTIVES: The purpose of this study was to determine the safety and efficacy of rescue echocardiographically guided pericardiocentesis as a primary strategy for the management of acute cardiac perforation and tamponade complicating catheter-based procedures. BACKGROUND: In this era of interventional catheterization, acute tamponade from cardiac perforation as a complication is encountered more frequently. The safety and efficacy of echocardiographically guided pericardiocentesis in this life-threatening situation and outcomes of patients managed by this technique are unknown. METHODS: Of the 960 consecutive echocardiographically guided pericardiocenteses performed at the Mayo Clinic (1979 to 1997), 92 (9.6%) were undertaken in 88 patients with acute tamponade that developed in association with a diagnostic or interventional catheter-based procedure. Most of the patients were hemodynamically unstable at the time of pericardiocentesis, with clinically overt tamponade in 40% and frank hemodynamic collapse (systolic blood pressure <60 mm Hg) in 57%. Clinical end points of interest were the success and complication rates of rescue pericardiocentesis and patient outcomes, including the need for other interventions, clinical and echocardiographic follow-up findings and survival. RESULTS: Rescue pericardiocentesis was successful in relieving tamponade in 91 cases (99%) and was the only and definitive therapy in 82% of the cases. Major complications (3%) included pneumothorax (n=1), right ventricular laceration (n=1) and intercostal vessel injury with right ventricular laceration (n=1); all were treated successfully. Minor complications (2%) included a small pneumothorax and an instance of transient nonsustained ventricular tachycardia; all were resolved spontaneously. Further surgical intervention was performed in 16 patients (18%). No deaths resulted from the rescue pericardiocentesis procedure itself. Early death (<30 days) in this series was due to injuries from cardiac catheter-based procedures (n=3), perioperative complications (n=2) and underlying cardiac diseases (n=2). Clinical or echocardiographic follow-up for a minimum of 3 months or until death (if <3 months) for recurrent effusion or development of pericardial constriction was achieved in 87 (99%) of the patients. CONCLUSIONS: Echocardiographically guided pericardiocentesis was safe and effective for rescuing patients from tamponade and reversing hemodynamic instability complicating invasive cardiac catheter-based procedures. For most patients, this was the definitive and only therapy necessary.     

Anaesthetic complications in the recovery room

INTRODUCTION: The immediate post-operative period in the recovery room is a known period of high risk for anaesthetic complications to occur. AIMS: We wanted to know the incidence and nature of our recovery room patients in the main-theatre complex of Hospital Kuala Lumpur. METHOD: A prospective study was conducted over a two-month period on all patients receiving either regional and/or general anaesthesia by an anaesthetic doctor admitted to this recovery room. Complications were documented according to predefined criteria. RESULTS: Out of a total of 1,995 patients, 50(2.5%) had some form of anaesthetic complication. Fifteen patients had more than one complication. The most common was pain (23 patients) followed closely by nausea and vomiting (21 patients). There were 32 patients with CNS problems (including the 23 with pain), 21 with GIT, 10 with CVS, 2 with respiratory and 3 with other problems. CONCLUSION: Our recovery room complication rate is acceptably low. Knowing the type and frequency of problems (in this case, mainly pain and nausea and vomiting) can further improve the figure. The role of anaesthesiologists has expanded as they are not only expected to ascertain the safety but also the comfort of patients post-operatively.