Thoracoscopy in the Treatment of Primary Recurrent Spontaneous Pneumothorax

Spontaneous pneumothorax is a common phenomenon particularly in young people. At present, disagreement remains concerning the best mode of therapy. Closed-tube thoracostomy is considered the main therapeutic approach for most patients. However, this method is usually ineffective in preventing recurrences. The only therapy able to prevent recurrence is surgical resection of the lung lesion with pleural abrasion. Treatment by thoracoscopy allowed us to achieve successful results in 24 patients with spontaneous pneumothorax. Recurrent (26 patients) or persistent (1 patient) spontaneous pneumothorax was treated by thoracoscopy. The patients’ ages ranged from 16 to 35 years (mean 22.6 years). Only patients with no known underlying pulmonary disease were accepted into this study. Thoracoscopy was performed under local anesthesia and parenteral sedation in the first 20 patients and general intubation anesthesia in the last 7 cases. All patients were informed about this procedure and the possible necessity of subsequent thoracostomy if the procedure failed. After exploration of the pleural cavity and evaluation of the lesions we attempted to achieve two basic objectives: (a) Act on the anatomical lesion which causes the pneumothorax by electrocoagulation of subpleural air spaces when visible, apical cautery scarificatiod, and apical sealing with fibrin glue. On the last seven patients apical resection with an endosuture stapler device and fibrin sealant apical sealing was performed. (b) Create pleural adhesions with fibrin sealant to facilitate tissue adhesion and performing multiple diffuse and superficial scarifications on the visceral pleura at the upper lobes without fibrin sealant. There were no recorded deaths related to the surgical procedure. In two of the first 20 patients recurrence was observed during the postoperative week, and thoracotomy was performed. A 35-year-old man of this group was discharged from hospital on the fourth postoperative day; however, 3 months later he was readmitted because of recurrence. The chest roentgenogram revealed a lower pneumothorax. At thoracotomy the upper lobe was strongly adherent, and small subpleural air spaces were detected in the apex lower lobe. The mean postoperative hospital stay of the remaining cases was 4.5 days. The follow-up period ranged from 2 to 59 months. During this period no recurrence was noted. In conclusion, considering the good results observed in these patients, we think that the thoracoscopic procedure should be considered the treatment of choice in selected patients with spontaneous pneumothorax.