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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction</span></p><p class="elsevierStylePara"> Video-assisted thoracoscopic surgery &#40;VATS&#41;&#44; dating from the early 1990s&#44; has revolutionized the treatment of several thoracic diseases and conditions<span class="elsevierStyleSup">1</span>&#46; Pneumothorax is among those that have benefited most from the gradually increasing use of VATS&#44; which provides a less invasive means to resolve a condition that is benign but of high prevalence among young patients<span class="elsevierStyleSup">2</span>&#46; Pneumothorax has become one of the most accepted indications for VATS<span class="elsevierStyleSup">3</span>&#46;</p><p class="elsevierStylePara">The standard initial treatment for spontaneous pneumothorax is thoracic drainage&#46; However&#44; if the problem is not resolved &#40;persistent pneumothorax&#41; or there is recurrence&#44; surgical treatment should be considered<span class="elsevierStyleSup">4&#44;5</span>&#46; The surgical techniques &#40;standard thoracotomy&#44; axillary thoracotomy and VATS&#41; enable closure of the air leaks that cause the pneumothorax&#44; wedge resection of the affected zone and&#47;or pleurectomy<span class="elsevierStyleSup">6</span>&#46;</p><p class="elsevierStylePara"> Spontaneous pneumothorax can be classified as primary &#40;due to rupture of a subpleural bleb in a normal pulmonary parenchyma&#41; or secondary &#40;when the air leak occurs in a diseased lung&#41;<span class="elsevierStyleSup">7</span>&#46; In both forms&#44; an important causal role is played by blebs and bullae&#44; which are present in a high percentage of patients and which can be detected during surgery<span class="elsevierStyleSup">8</span>&#46; VATS is therefore an ideal procedure for detecting such macroscopic lesions&#44; and their resection by endoscopic linear cutter has become the treatment of choice<span class="elsevierStyleSup">9</span>&#46;</p><p class="elsevierStylePara">The present paper describes the indications for VATS in our hospital and the technique applied&#44; as well as the complications and results observed over a three-year period&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Material and methods</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Patients</span></p><p class="elsevierStylePara">A prospective study was carried out on 238 VATS interventions taking place over a period of 37 months&#46; In 107 interventions &#40;44&#37;&#41; the indication for surgery was primary or secondary pneumothorax&#46;</p><p class="elsevierStylePara"> Surgery was performed on 105 patients &#40;78 men and 27 women&#41; with a mean age of 28&#46;78&#177;13&#46;96 years &#40;range&#58; 15&#173;78 years&#41;&#46;</p><p class="elsevierStylePara"> Indications for surgery were the following&#58; recurrent ipsilateral pneumothorax &#40;47 cases&#41;&#59; persistent air leak for more than five days even after checking correct placement of and active drainage from the chest tube<span class="elsevierStyleSup">10</span> &#40;23 cases&#41;&#59; hypertensive pneumothorax &#40;14 cases&#41;&#59; a history of contralateral pneumothorax &#40;13 cases&#41;&#59; and elective surgery &#40;10 cases&#41;&#46; See Table 1&#46;</p><p class="elsevierStylePara"><img src="260v39n07-13046506tab01.gif"></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Surgical technique</span></p><p class="elsevierStylePara">All procedures were performed with general anesthesia and selective intubation&#46; The patient was in lateral decubitus position&#44; resting on the side opposite the pneumothorax&#46; After selective blocking of the affected lung&#44; the surgeon made a first incision at the sixth or seventh intercostal space on the medial axillary line and a 10 mm trocar was inserted followed by a 0-degree optic&#46; With video-assisted guidance two more trocars &#40;diameters&#58; 10 mm and 12 mm&#41; were inserted into the chest cavity at the fourth intercostal space on the anterior axillary line and at the fifth intercostal space on the posterior axillary line&#44; respectively&#46; In no case was carbon dioxide used to aid in the formation of a thoracic space&#46; After triangulation from the trocars&#44; we explored the lung with an Endoscopic Blunt Dissector &#40;BCD 10&#44; Ethicon Endo-Surgery Inc&#46;&#44; Cincinnati&#44; Ohio&#44; U&#46;S&#46;A&#46;&#41; to detect blebs or bullae causing air leaks&#46; If adhesions were found&#44; they were removed by electrocoagulation and scissors&#46; An Endoscopic Articulating Linear Cutter &#40;ETS -&#173; Flex 45&#44; Ethicon Endo-Surgery Inc&#46;&#44; Cincinnati&#44; Ohio&#44; U&#46;S&#46;A&#46;&#41; was used whenever lesions were found&#44; but if none were visualized&#44; a small portion of the pulmonary apex was biopsied for histopathologic study&#46; The mean number of firing strokes was 2&#46;7 per patient &#40;range&#58; 1-7&#41;&#46;</p><p class="elsevierStylePara">The cavity was then washed with physiological saline solution to check for the continued presence of air leaks&#46; Finally physical pleurodesis was performed by abrasion&#46; Talc insufflation was never performed&#46;</p><p class="elsevierStylePara">In all cases a chest tube &#40;24 F&#41; was inserted through the trocar situated on the medial axillary line and was connected to an aspirator of &#173;-20 cm H<span class="elsevierStyleInf">2</span>O&#46; In the cases of conversion to thoracotomy&#44; two chest tubes were inserted&#46;</p><p class="elsevierStylePara">The patients receiving VATS treatment were taken to the recovery room where they remained for a mean duration of 120 minutes &#40;range&#58; 60-180&#41; before being taken to the ward&#46; No patient required transfer to the postoperative intensive care unit&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Results</span></p><p class="elsevierStylePara">Of the 107 VATS interventions&#44; 83 &#40;77&#46;6&#37;&#41; involved primary pneumothorax and 24 &#40;22&#46;4&#37;&#41; involved secondary pneumothorax&#46;</p><p class="elsevierStylePara"> There were no perioperative deaths&#46; Conversion to posterolateral thoracotomy took place in three cases&#58; one due to inadequate pulmonary blocking and two due to large pleuropulmonary adhesions detected on the mediastinal zone&#46; These latter two cases were men with secondary pneumothoraces&#44; in one of whom the pneumothorax was a recurrence&#46;</p><p class="elsevierStylePara"> Perioperative complications developed in 16 cases&#46; &#40;See Table 2&#46;&#41; In 13 of these cases the complications were resolved through unassisted observation or by replacing the chest drainage tube&#46; A second intervention was necessary in four cases &#40;3&#46;7&#37;&#41;&#46;</p><p class="elsevierStylePara"><img src="260v39n07-13046506tab02.gif"></img></p><p class="elsevierStylePara">In two cases&#44; an immediate postoperative intervention was performed due to hemorrhaging 6 and 18 hours&#44; respectively&#44; after the VATS&#46; In one of these cases a transfusion of one unit of packed red blood cells was required&#46; Both patients had undergone VATS for large mediastinal adhesions and in both cases the hemorrhage was located in an arteriole in the mediastinal region&#46; The two other VATS-treated cases required re-intervention on the seventh and eighth day&#44; respectively&#44; to correct persistent air leak&#46; In all four cases a posterolateral thoracotomy was performed&#46;</p><p class="elsevierStylePara"> During 93 interventions &#40;86&#46;91&#37;&#41; lung disease was identified as the cause or the presumed cause of the pneumothorax&#59; thus resection was performed&#46;</p><p class="elsevierStylePara"> Chest tubes were removed a mean 1&#46;96&#177;1&#46;01 days after surgery &#40;range&#58; 1-8 days&#41;&#46; The mean postoperative hospital stay was 3&#46;64 days &#40;range&#58; 3-12&#41;&#46;</p><p class="elsevierStylePara">Two patients experienced a postoperative recurrence &#40;ipsilateral pneumothorax &#60;10&#37;&#41; following removal of the chest tube&#46; They required no more than routine monitoring during out-patient appointments&#46;</p><p class="elsevierStylePara">In the cases of two other patients&#44; postoperative recurrences during the follow-up period were diagnosed when the patients came to our emergency room&#46; These patients required more radical treatment&#46; One woman with secondary pneumothorax suffered two episodes of partial basal ipsilateral pneumothorax eight and twelve months&#44; respectively&#44; after surgery&#46; These two recurrences were successfully treated by chest drainage&#46; The other patient&#44; although young and presenting no risk factors&#44; suffered a recurrence of 25&#37; pneumothorax four months after surgery and required a thoracotomy&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion</span></p><p class="elsevierStylePara"> Spontaneous primary pneumothorax&#44; traditionally treated by axillary thoracotomy&#44; has become one of the most accepted indications for VATS<span class="elsevierStyleSup">2&#44;9</span>&#46; In the case of secondary pneumothorax&#44; VATS is gradually becoming a more accepted treatment<span class="elsevierStyleSup">11</span>&#44; although the presence of lung disease is a source of higher rate of complications<span class="elsevierStyleSup">12</span>&#46;</p><p class="elsevierStylePara">The cause of lesions in primary pneumothorax is not entirely understood&#46; They may be the result of a break in the alveolar wall&#44; causing air to leak into the pulmonary interstitial spaces and pleural viscera&#44; forming small subpleural vesiculae<span class="elsevierStyleSup">13</span>&#46; In secondary pneumothorax&#44; a demonstrated pulmonary disease would be the cause of the clinical picture&#46; In the 24 cases of secondary pneumothorax in our study&#44; the underlying pulmonary diseases were the following&#58; chronic obstructive pulmonary disease&#47;bullous emphysema &#40;18 cases&#41;&#59; infection in immunodepressed patients &#40;4 cases&#41;&#59; Langerhans cell histiocytosis &#40;2 cases&#41;&#46; There was a higher percentage of complications among secondary pneumothorax patients&#44; as reflected in Table 2&#46;</p><p class="elsevierStylePara"> Spontaneous pneumothorax recurs after chest drainage treatment of a first episode in 20 to 25&#37;<span class="elsevierStyleSup">14&#44;15</span> of patients&#46; In our study&#44; the rate of recurrence after VATS treatment was 1&#46;8&#37;&#58; two patients who suffered an ipsilateral pneumothorax&#46; Only one of these patients received surgical treatment in a follow-up period limited to 14 months&#46; In the series studied&#44; the mean period of postoperative follow-up was 14&#46;4 months &#40;range&#58; 2-36 months&#41;&#46;</p><p class="elsevierStylePara"> Some patients&#44; for work-related or personal reasons&#44; requested surgery at the first episode &#40;elective surgery&#41;&#46; This surgery was performed in 10 cases with no postoperative complications or recurrences&#46; All 10 patients were operated on within a few days of the first episode and postoperative chest tubes were inserted&#46;</p><p class="elsevierStylePara">The surgical technique used was insertion of three trocars &#40;for proper triangulation&#41; and resection by endoscopic stapler of the diseased zones &#40;bullae or blebs&#41;&#44; generally on the superior lobe&#46; After checking for absence of air leaks&#44; physical pleurodesis was performed&#46; We performed neither talc insufflation &#40;recurrence 1&#46;79&#37;&#41; nor apical pleurectomy &#40;recurrence 9&#46;15&#37;&#41;&#44; although some authors report recurrence rates of postoperative pneumothorax above and below ours &#40;7&#37;&#41;&#46; In some cases in our study&#44; no chest tubes and&#47;or thoracotomies were required&#46; In our opinion talc&#44; an adhesive agent of tested effectiveness&#44; should be used only in patients with malignant pleural effusions&#46; We did not use biological sealants&#44; as we consider their high cost and debatable effectiveness for treating spontaneous pneumothorax<span class="elsevierStyleSup">16</span> does not make them a viable option&#46;</p><p class="elsevierStylePara">In patients in whom no lung disease was evident &#40;14 cases&#41;&#44; a biopsy of the most apical part was performed by one or two firing strokes followed by physical pleurodesis&#46; Sometimes subpleural blebs are difficult to see and a thorough inspection of the lung is needed&#46; For such an exploration we use a blunt dissector which permits us to turn the surface of the parenchyma back&#44; thus avoiding unnecessary traction which may lead to postoperative air leaks&#46; This technique requires manual reexpansion of the lung by the anesthetist to provide a view of lesions which may be hidden by the atelectasis&#46; One among those patients suffered a recurrence of pneumothorax &#40;&#60;10&#37;&#41; which only required out-patient management&#46;</p><p class="elsevierStylePara">The mean duration of the postoperative hospital stay was 3&#46;64 days&#46; In the cases of pneumothorax treated by thoracotomy &#40;axillary or posterolateral&#41;&#44; the mean postoperative stay was 5&#46;67 days&#44; with 38&#37; also requiring admission to a postoperative intensive care unit&#46;</p><p class="elsevierStylePara">In conclusion&#44; we consider that inserting a chest tube for drainage is the first measure to take on diagnosing spontaneous pneumothorax&#46; In cases of contralateral or hypertensive pneumothorax&#44; we opt for surgery&#44; with VATS being our preferred technique&#46; VATS is also the first technique we consider for treating persistent pneumothorax&#46;</p><p class="elsevierStylePara">A thorough VATS exploration of the pulmonary parenchyma identifies lesions in a high percentage of patients because an endoscopic video camera offers a better view of the site than can be obtained by axillary thoracotomy&#46;</p><p class="elsevierStylePara">The low rate of complications and the good long range results&#44; in terms of short hospital stays and rapid functional recovery&#44; make VATS our technique of choice in the treatment of both primary and secondary spontaneous pneumothoraces&#46;</p><hr></hr><p class="elsevierStylePara">Correspondence&#58; Dr&#46; J&#46;M&#46; Galbis Caravajal&#46;<br></br> Hospital General Universitario de Alicante&#46;<br></br> Maestro Alonso&#44; 109&#46; 03010 Alicante&#46; Spain&#46;<br></br> E-mail&#58; <a href="mailto&#58;galbis&#95;jos&#64;gva&#46;es" class="elsevierStyleCrossRefs"> galbis&#95;jos&#64;gva&#46;es</a></p><p class="elsevierStylePara">Mauscript received 6 October 2002&#46;<br></br> Accepted for publication 12 October 2002&#46;</p>"
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        "resumen" => "The aim of this prospective study was to evaluate video-assisted thoracoscopic surgery &#40;VATS&#41; in primary and secondary spontaneous pneumothoraces&#46; Over a 37-month period&#44; 107 videothoracoscopic interventions were performed to treat spontaneous pneumothorax in 105 patients&#44; 78 men and 27 women&#44; whose average age was 28 years&#46; Indications for surgery included recurrent ipsilateral pneumothorax &#40;47 cases&#41;&#44; persistent air leak &#40;23 cases&#41;&#44; hypertensive pneumothorax &#40;14 cases&#41;&#44; history of contralateral pneumothorax &#40;13 cases&#41;&#44; and elective surgery &#40;10 cases&#41;&#46; All of these patients were treated by endoscopic resection of the bullae &#40;or apical zone in cases where the suspected abnormalities&#44; or bullae&#44; could not be visualized&#41; plus physical pleurodesis&#46; There were no perioperative deaths&#46; Complications occurred in 6&#37; of the cases of primary spontaneous pneumothorax and in 45&#37; of the cases of secondary spontaneous pneumothorax&#46; The complications among the secondary pneumothorax patients ranged widely from postoperative subcutaneous emphysema &#40;resolved through simple&#44; unassisted observation&#41; to the need for an accessory minithoracotomy&#46; Two patients &#40;1&#46;8&#37;&#41; suffered a recurrence of pneumothorax 4 and 8 months&#44; respectively&#44; after VATS treatment&#46;"
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Video-assisted thoracoscopic surgery in the treatment of pneumothorax: 107 consecutive procedures
Cirugía videotoracoscópica en el tratamiento de los neumotórax: consideraciones sobre 107 procedimientos consecutivos
JM. Galbis Caravajala, JJ. Mafé Madueñoa, S. Benlloch Carriónb, B. Baschwitz Gómeza, JM. Rodríguez Paniaguaa
a Servicio de Cirugía Torácica. Hospital General Universitario de Alicante. Alicante. Spain.
b Unidad de Investigación. Hospital General Universitario de Alicante. Alicante. Spain.
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction</span></p><p class="elsevierStylePara"> Video-assisted thoracoscopic surgery &#40;VATS&#41;&#44; dating from the early 1990s&#44; has revolutionized the treatment of several thoracic diseases and conditions<span class="elsevierStyleSup">1</span>&#46; Pneumothorax is among those that have benefited most from the gradually increasing use of VATS&#44; which provides a less invasive means to resolve a condition that is benign but of high prevalence among young patients<span class="elsevierStyleSup">2</span>&#46; Pneumothorax has become one of the most accepted indications for VATS<span class="elsevierStyleSup">3</span>&#46;</p><p class="elsevierStylePara">The standard initial treatment for spontaneous pneumothorax is thoracic drainage&#46; However&#44; if the problem is not resolved &#40;persistent pneumothorax&#41; or there is recurrence&#44; surgical treatment should be considered<span class="elsevierStyleSup">4&#44;5</span>&#46; The surgical techniques &#40;standard thoracotomy&#44; axillary thoracotomy and VATS&#41; enable closure of the air leaks that cause the pneumothorax&#44; wedge resection of the affected zone and&#47;or pleurectomy<span class="elsevierStyleSup">6</span>&#46;</p><p class="elsevierStylePara"> Spontaneous pneumothorax can be classified as primary &#40;due to rupture of a subpleural bleb in a normal pulmonary parenchyma&#41; or secondary &#40;when the air leak occurs in a diseased lung&#41;<span class="elsevierStyleSup">7</span>&#46; In both forms&#44; an important causal role is played by blebs and bullae&#44; which are present in a high percentage of patients and which can be detected during surgery<span class="elsevierStyleSup">8</span>&#46; VATS is therefore an ideal procedure for detecting such macroscopic lesions&#44; and their resection by endoscopic linear cutter has become the treatment of choice<span class="elsevierStyleSup">9</span>&#46;</p><p class="elsevierStylePara">The present paper describes the indications for VATS in our hospital and the technique applied&#44; as well as the complications and results observed over a three-year period&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Material and methods</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Patients</span></p><p class="elsevierStylePara">A prospective study was carried out on 238 VATS interventions taking place over a period of 37 months&#46; In 107 interventions &#40;44&#37;&#41; the indication for surgery was primary or secondary pneumothorax&#46;</p><p class="elsevierStylePara"> Surgery was performed on 105 patients &#40;78 men and 27 women&#41; with a mean age of 28&#46;78&#177;13&#46;96 years &#40;range&#58; 15&#173;78 years&#41;&#46;</p><p class="elsevierStylePara"> Indications for surgery were the following&#58; recurrent ipsilateral pneumothorax &#40;47 cases&#41;&#59; persistent air leak for more than five days even after checking correct placement of and active drainage from the chest tube<span class="elsevierStyleSup">10</span> &#40;23 cases&#41;&#59; hypertensive pneumothorax &#40;14 cases&#41;&#59; a history of contralateral pneumothorax &#40;13 cases&#41;&#59; and elective surgery &#40;10 cases&#41;&#46; See Table 1&#46;</p><p class="elsevierStylePara"><img src="260v39n07-13046506tab01.gif"></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Surgical technique</span></p><p class="elsevierStylePara">All procedures were performed with general anesthesia and selective intubation&#46; The patient was in lateral decubitus position&#44; resting on the side opposite the pneumothorax&#46; After selective blocking of the affected lung&#44; the surgeon made a first incision at the sixth or seventh intercostal space on the medial axillary line and a 10 mm trocar was inserted followed by a 0-degree optic&#46; With video-assisted guidance two more trocars &#40;diameters&#58; 10 mm and 12 mm&#41; were inserted into the chest cavity at the fourth intercostal space on the anterior axillary line and at the fifth intercostal space on the posterior axillary line&#44; respectively&#46; In no case was carbon dioxide used to aid in the formation of a thoracic space&#46; After triangulation from the trocars&#44; we explored the lung with an Endoscopic Blunt Dissector &#40;BCD 10&#44; Ethicon Endo-Surgery Inc&#46;&#44; Cincinnati&#44; Ohio&#44; U&#46;S&#46;A&#46;&#41; to detect blebs or bullae causing air leaks&#46; If adhesions were found&#44; they were removed by electrocoagulation and scissors&#46; An Endoscopic Articulating Linear Cutter &#40;ETS -&#173; Flex 45&#44; Ethicon Endo-Surgery Inc&#46;&#44; Cincinnati&#44; Ohio&#44; U&#46;S&#46;A&#46;&#41; was used whenever lesions were found&#44; but if none were visualized&#44; a small portion of the pulmonary apex was biopsied for histopathologic study&#46; The mean number of firing strokes was 2&#46;7 per patient &#40;range&#58; 1-7&#41;&#46;</p><p class="elsevierStylePara">The cavity was then washed with physiological saline solution to check for the continued presence of air leaks&#46; Finally physical pleurodesis was performed by abrasion&#46; Talc insufflation was never performed&#46;</p><p class="elsevierStylePara">In all cases a chest tube &#40;24 F&#41; was inserted through the trocar situated on the medial axillary line and was connected to an aspirator of &#173;-20 cm H<span class="elsevierStyleInf">2</span>O&#46; In the cases of conversion to thoracotomy&#44; two chest tubes were inserted&#46;</p><p class="elsevierStylePara">The patients receiving VATS treatment were taken to the recovery room where they remained for a mean duration of 120 minutes &#40;range&#58; 60-180&#41; before being taken to the ward&#46; No patient required transfer to the postoperative intensive care unit&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Results</span></p><p class="elsevierStylePara">Of the 107 VATS interventions&#44; 83 &#40;77&#46;6&#37;&#41; involved primary pneumothorax and 24 &#40;22&#46;4&#37;&#41; involved secondary pneumothorax&#46;</p><p class="elsevierStylePara"> There were no perioperative deaths&#46; Conversion to posterolateral thoracotomy took place in three cases&#58; one due to inadequate pulmonary blocking and two due to large pleuropulmonary adhesions detected on the mediastinal zone&#46; These latter two cases were men with secondary pneumothoraces&#44; in one of whom the pneumothorax was a recurrence&#46;</p><p class="elsevierStylePara"> Perioperative complications developed in 16 cases&#46; &#40;See Table 2&#46;&#41; In 13 of these cases the complications were resolved through unassisted observation or by replacing the chest drainage tube&#46; A second intervention was necessary in four cases &#40;3&#46;7&#37;&#41;&#46;</p><p class="elsevierStylePara"><img src="260v39n07-13046506tab02.gif"></img></p><p class="elsevierStylePara">In two cases&#44; an immediate postoperative intervention was performed due to hemorrhaging 6 and 18 hours&#44; respectively&#44; after the VATS&#46; In one of these cases a transfusion of one unit of packed red blood cells was required&#46; Both patients had undergone VATS for large mediastinal adhesions and in both cases the hemorrhage was located in an arteriole in the mediastinal region&#46; The two other VATS-treated cases required re-intervention on the seventh and eighth day&#44; respectively&#44; to correct persistent air leak&#46; In all four cases a posterolateral thoracotomy was performed&#46;</p><p class="elsevierStylePara"> During 93 interventions &#40;86&#46;91&#37;&#41; lung disease was identified as the cause or the presumed cause of the pneumothorax&#59; thus resection was performed&#46;</p><p class="elsevierStylePara"> Chest tubes were removed a mean 1&#46;96&#177;1&#46;01 days after surgery &#40;range&#58; 1-8 days&#41;&#46; The mean postoperative hospital stay was 3&#46;64 days &#40;range&#58; 3-12&#41;&#46;</p><p class="elsevierStylePara">Two patients experienced a postoperative recurrence &#40;ipsilateral pneumothorax &#60;10&#37;&#41; following removal of the chest tube&#46; They required no more than routine monitoring during out-patient appointments&#46;</p><p class="elsevierStylePara">In the cases of two other patients&#44; postoperative recurrences during the follow-up period were diagnosed when the patients came to our emergency room&#46; These patients required more radical treatment&#46; One woman with secondary pneumothorax suffered two episodes of partial basal ipsilateral pneumothorax eight and twelve months&#44; respectively&#44; after surgery&#46; These two recurrences were successfully treated by chest drainage&#46; The other patient&#44; although young and presenting no risk factors&#44; suffered a recurrence of 25&#37; pneumothorax four months after surgery and required a thoracotomy&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion</span></p><p class="elsevierStylePara"> Spontaneous primary pneumothorax&#44; traditionally treated by axillary thoracotomy&#44; has become one of the most accepted indications for VATS<span class="elsevierStyleSup">2&#44;9</span>&#46; In the case of secondary pneumothorax&#44; VATS is gradually becoming a more accepted treatment<span class="elsevierStyleSup">11</span>&#44; although the presence of lung disease is a source of higher rate of complications<span class="elsevierStyleSup">12</span>&#46;</p><p class="elsevierStylePara">The cause of lesions in primary pneumothorax is not entirely understood&#46; They may be the result of a break in the alveolar wall&#44; causing air to leak into the pulmonary interstitial spaces and pleural viscera&#44; forming small subpleural vesiculae<span class="elsevierStyleSup">13</span>&#46; In secondary pneumothorax&#44; a demonstrated pulmonary disease would be the cause of the clinical picture&#46; In the 24 cases of secondary pneumothorax in our study&#44; the underlying pulmonary diseases were the following&#58; chronic obstructive pulmonary disease&#47;bullous emphysema &#40;18 cases&#41;&#59; infection in immunodepressed patients &#40;4 cases&#41;&#59; Langerhans cell histiocytosis &#40;2 cases&#41;&#46; There was a higher percentage of complications among secondary pneumothorax patients&#44; as reflected in Table 2&#46;</p><p class="elsevierStylePara"> Spontaneous pneumothorax recurs after chest drainage treatment of a first episode in 20 to 25&#37;<span class="elsevierStyleSup">14&#44;15</span> of patients&#46; In our study&#44; the rate of recurrence after VATS treatment was 1&#46;8&#37;&#58; two patients who suffered an ipsilateral pneumothorax&#46; Only one of these patients received surgical treatment in a follow-up period limited to 14 months&#46; In the series studied&#44; the mean period of postoperative follow-up was 14&#46;4 months &#40;range&#58; 2-36 months&#41;&#46;</p><p class="elsevierStylePara"> Some patients&#44; for work-related or personal reasons&#44; requested surgery at the first episode &#40;elective surgery&#41;&#46; This surgery was performed in 10 cases with no postoperative complications or recurrences&#46; All 10 patients were operated on within a few days of the first episode and postoperative chest tubes were inserted&#46;</p><p class="elsevierStylePara">The surgical technique used was insertion of three trocars &#40;for proper triangulation&#41; and resection by endoscopic stapler of the diseased zones &#40;bullae or blebs&#41;&#44; generally on the superior lobe&#46; After checking for absence of air leaks&#44; physical pleurodesis was performed&#46; We performed neither talc insufflation &#40;recurrence 1&#46;79&#37;&#41; nor apical pleurectomy &#40;recurrence 9&#46;15&#37;&#41;&#44; although some authors report recurrence rates of postoperative pneumothorax above and below ours &#40;7&#37;&#41;&#46; In some cases in our study&#44; no chest tubes and&#47;or thoracotomies were required&#46; In our opinion talc&#44; an adhesive agent of tested effectiveness&#44; should be used only in patients with malignant pleural effusions&#46; We did not use biological sealants&#44; as we consider their high cost and debatable effectiveness for treating spontaneous pneumothorax<span class="elsevierStyleSup">16</span> does not make them a viable option&#46;</p><p class="elsevierStylePara">In patients in whom no lung disease was evident &#40;14 cases&#41;&#44; a biopsy of the most apical part was performed by one or two firing strokes followed by physical pleurodesis&#46; Sometimes subpleural blebs are difficult to see and a thorough inspection of the lung is needed&#46; For such an exploration we use a blunt dissector which permits us to turn the surface of the parenchyma back&#44; thus avoiding unnecessary traction which may lead to postoperative air leaks&#46; This technique requires manual reexpansion of the lung by the anesthetist to provide a view of lesions which may be hidden by the atelectasis&#46; One among those patients suffered a recurrence of pneumothorax &#40;&#60;10&#37;&#41; which only required out-patient management&#46;</p><p class="elsevierStylePara">The mean duration of the postoperative hospital stay was 3&#46;64 days&#46; In the cases of pneumothorax treated by thoracotomy &#40;axillary or posterolateral&#41;&#44; the mean postoperative stay was 5&#46;67 days&#44; with 38&#37; also requiring admission to a postoperative intensive care unit&#46;</p><p class="elsevierStylePara">In conclusion&#44; we consider that inserting a chest tube for drainage is the first measure to take on diagnosing spontaneous pneumothorax&#46; In cases of contralateral or hypertensive pneumothorax&#44; we opt for surgery&#44; with VATS being our preferred technique&#46; VATS is also the first technique we consider for treating persistent pneumothorax&#46;</p><p class="elsevierStylePara">A thorough VATS exploration of the pulmonary parenchyma identifies lesions in a high percentage of patients because an endoscopic video camera offers a better view of the site than can be obtained by axillary thoracotomy&#46;</p><p class="elsevierStylePara">The low rate of complications and the good long range results&#44; in terms of short hospital stays and rapid functional recovery&#44; make VATS our technique of choice in the treatment of both primary and secondary spontaneous pneumothoraces&#46;</p><hr></hr><p class="elsevierStylePara">Correspondence&#58; Dr&#46; J&#46;M&#46; Galbis Caravajal&#46;<br></br> Hospital General Universitario de Alicante&#46;<br></br> Maestro Alonso&#44; 109&#46; 03010 Alicante&#46; Spain&#46;<br></br> E-mail&#58; <a href="mailto&#58;galbis&#95;jos&#64;gva&#46;es" class="elsevierStyleCrossRefs"> galbis&#95;jos&#64;gva&#46;es</a></p><p class="elsevierStylePara">Mauscript received 6 October 2002&#46;<br></br> Accepted for publication 12 October 2002&#46;</p>"
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        "resumen" => "The aim of this prospective study was to evaluate video-assisted thoracoscopic surgery &#40;VATS&#41; in primary and secondary spontaneous pneumothoraces&#46; Over a 37-month period&#44; 107 videothoracoscopic interventions were performed to treat spontaneous pneumothorax in 105 patients&#44; 78 men and 27 women&#44; whose average age was 28 years&#46; Indications for surgery included recurrent ipsilateral pneumothorax &#40;47 cases&#41;&#44; persistent air leak &#40;23 cases&#41;&#44; hypertensive pneumothorax &#40;14 cases&#41;&#44; history of contralateral pneumothorax &#40;13 cases&#41;&#44; and elective surgery &#40;10 cases&#41;&#46; All of these patients were treated by endoscopic resection of the bullae &#40;or apical zone in cases where the suspected abnormalities&#44; or bullae&#44; could not be visualized&#41; plus physical pleurodesis&#46; There were no perioperative deaths&#46; Complications occurred in 6&#37; of the cases of primary spontaneous pneumothorax and in 45&#37; of the cases of secondary spontaneous pneumothorax&#46; The complications among the secondary pneumothorax patients ranged widely from postoperative subcutaneous emphysema &#40;resolved through simple&#44; unassisted observation&#41; to the need for an accessory minithoracotomy&#46; Two patients &#40;1&#46;8&#37;&#41; suffered a recurrence of pneumothorax 4 and 8 months&#44; respectively&#44; after VATS treatment&#46;"
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]
Article information
ISSN: 15792129
Original language: English
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