Elsevier

The Annals of Thoracic Surgery

Volume 98, Issue 6, December 2014, Pages 2005-2011
The Annals of Thoracic Surgery

Original article
General thoracic
Staple Line Coverage After Bullectomy for Primary Spontaneous Pneumothorax: A Randomized Trial

https://doi.org/10.1016/j.athoracsur.2014.06.047Get rights and content

Background

Thoracoscopic wedge resection is generally accepted as a standard surgical procedure for primary spontaneous pneumothorax. Because of the relatively high recurrence rate after surgery, additional procedures such as mechanical pleurodesis or visceral pleural coverage are usually applied to minimize recurrence, although mechanical pleurodesis has some potential disadvantages. The aim of this study was to clarify whether an additional coverage procedure on the staple line after thoracoscopic bullectomy prevents postoperative recurrence compared with additional pleurodesis.

Methods

A total of 1,414 patients in 11 hospitals with primary spontaneous pneumothorax undergoing thoracoscopic bullectomy were enrolled. After bullectomy with staplers, patients were randomly assigned to either the coverage group (n = 757) or the pleurodesis group (n = 657). In the coverage group, the staple line was covered with absorbable cellulose mesh and fibrin glue. The pleurodesis group underwent additional mechanical abrasion on the parietal pleura.

Results

The coverage group and the pleurodesis group showed comparable surgical outcomes. After a median follow-up of 19.5 months, the postoperative 1-year recurrence rate was 9.5% in the coverage group and 10.7% in the pleurodesis group. The 1-year recurrence rate requiring intervention was 5.8% in the coverage group and 7.8% in the pleurodesis group. The coverage group showed better recovery from pain.

Conclusions

In terms of postoperative recurrence rate, visceral pleural coverage after thoracoscopic bullectomy was not inferior to mechanical pleurodesis. Visceral pleural coverage may potentially replace mechanical pleurodesis, which has potential disadvantages such as disturbed normal pleural physiology.

Section snippets

Study Design

Between October 2006 and July 2010, a total of 1,414 patients with PSP who underwent thoracoscopic bullectomy were enrolled in a prospective, multicenter, randomized, controlled study to investigate efficacy of coverage after thoracoscopic bullectomy. The minimum follow-up period was 1 year, and all except 16 patients who failed this requirement were followed up at least until June 2011. Eligibility criteria included ipsilateral or bilateral recurrent pneumothorax, history of previous

Patients

The median age of the 1,414 patients (1,295 male; 91.6%) was 18 years (range, 15 to 35 years), and 990 patients were never-smokers. Operations were performed for right pneumothorax in 652 patients (46.1%) and left pneumothorax in 761 patients (53.8%), with no clinical differences between the two groups (Table 1).

Operations

All underwent the VATS procedure successfully without conversion or mortality. Causes of operation were recurrent PSP (567 patients; 40.1%), tension pneumothorax (93 patients; 6.6%),

Comment

We set out to compare the prevention of PSP recurrence after thoracoscopic bullectomy by additional staple line coverage or additional mechanical pleurodesis. Although primary management of PSP is closed thoracostomy, the surgical indications for PSP have been broadened by advances in minimally invasive surgery and perioperative care. Video-assisted thoracic surgery has showed many advantages, such as reduced operation time, reduced drainage time, reduced complication rates, lower inflammatory

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  • Cited by (0)

    Dr Sungsoo Lee's current address is Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.

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