VATS Treatment of Spontaneous Pneumothorax William R. Mayfield, MD, FACS WellStar Thoracic Surgery March 2009

Etiology –Bleb rupture Primary Secondary

Consensus Statement Management of Spontaneous Pneumothorax** An American College of Chest Physicians Delphi Consensus Statement MICHAEL H. BAUMANNMICHAEL H. BAUMANN, MD, FCCP, et al FOR THE ACCP PNEUMOTHORAX CONSENSUS GROUP†† CHEST FEBRUARY 2001 VOL. 119 NO

Primary Spontaneous Pneumothorax Clinically Stable Small Pneumothorax –Observe in ER for 3-6 hrs –Repeat CXR –If no progression: discharge home –If distant from ER, or compliance unreliable, then admit

Primary Spontaneous Pneumothorax Clinically stable Large pneumothorax –Small bore catheter, 14 fr to 22 fr –Water seal –Suction if no re-expansion –Remove chest tube when no air leak –Discharge with one-way valve if unwilling to be admitted

Primary Spontaneous Pneumothorax Unstable Large pneumothorax –Chest tube 16 – 22 fr if small leak anticipated –Chest tube 24 – 28 fr if large leak anticipated, or positive pressure ventilation anticipated –Water seal –Suction if lung fails to expand –Remove tube when no leak and lung expanded

Persistent Air Leak Greater than 4 days Thoracoscopy –Closure of leak –Pleurodesis Bedside pleurodesis –Only if surgery contra-indicated or patient refuses surgery –Doxycycline or talc slurry

Pneumothorax Recurrence Prevention First pneumothorax15% of panel Second pneumothorax 85% of panel Decision modified by desire to fly or scuba Thoracoscopy is treatment of choice –95 – 100% success –Bullectomy –Parietal pleural abrasion of upper 50% –Pleurectomy is acceptable –Talc: no consensus Bedside pleurodesis for high risk patients –78 – 91% success

Primary Spontaneous Pneumothorax CT scanning –No consensus for first time pneumothorax –No consensus for second time pneumothorax, persistent air leak, or planned surgery

VATS Bullectomy and Pleurectomy

Position –Lateral decubitus, flexed Incisions –Two incision technique: 3 rd and 6 th interspace

Video –5 mm chip on a stick (Olympus) Endo GIA –Green load Duet in bullous disease

Case Report 87 yo male Metastatic angio-sarcoma Multiple pulmonary blebs after chemotherapy Recurrent left pneumothorax Failed bedside talc pleurodesis –prior admission

VATS Pleurectomy with talc

Conclusions There is consensus on treatment of spontaneous pneumothorax It is acceptable to operate on first time pneumothorax Thoracoscopy is the preferred method Pleurodesis by abrasion, pleurectomy, or (sometimes) talc is acceptable