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A. Imperatori et al. / Interactive CardioVascular and Thoracic Surgery
Regarding the second question, this is another key point. You are right, in the analysis of our data, three out of four female patients with recurrence had endometriosis, and in two of these, we were able to detect intraoperatively by inspection of the diaphragm the typical brown fenestration. These two patients underwent hormonal therapy. Unfortunately, just in one case we were able to show pathologically that this was a site of endometriosis. The other case was just necrotic tissue, probably because we were in the menstrual period of the patient. In conclusion, it’s very important to focus on a correct inspection of the diaphragm before performing VATS surgery for pneumothorax in young women. Dr G. Cardillo (Rome, Italy): I have a short question for you. All of us know that the key point for recurrence prevention is the pleurodesis, not the bullectomy. Recurrence rate showed 6%. In my opinion that is too high, so try to reconsider the partial pleurectomy, which seems not enough for recurrence prevention in light of your 6% recurrence rate. Can you comment on that? Dr Imperatori: You are right. This study enrolled patients until 2010, and we retrospectively evaluated our data. We are now considering performing, when possible, talc poudrage for pleurodesis. This could be the solution to avoid basal recurrence and to let the drainage for a shorter time. Moreover, it could reduce the postoperative air leakage that could be due to an incomplete resection of the bullae or when stapling lung resection falls on dystrophic tissue. Dr A. Sihoe (Hong Kong, China): Just two very quick questions. First point, you mentioned a lot of patients had recurrence quite late, and I think that’s something that we’re starting to realize all around the world. So, in the future, instead of just reporting a recurrence rate after an average of so many months, don’t you think it’s actually more appropriate that we do a survival analysis to study recurrences? The second question is: most studies on recurrence after surgery tend to focus on patient factors like female, age and also intraoperative factors. But I think points that we’re neglecting are the postoperative factors, how much pain the patient is in, what analgesia they’re given, how much suction we apply, is there an appearance of a rim of air after we remove the chest tubes? Did you consider looking at these factors? Dr Imperatori: For the first question, I agree with you. Late recurrence is very important because if we had completed our follow-up after four years, as reported in several studies, we would have lost 50% of recurrence in our centre, and we could show a 3% recurrence rate. For the suggested survival analysis, it could not be the right approach because recurrence is usually a rare event. The second point is pain. As I briefly showed you, we had 10% of ipsilateral chest wall dysaesthesia and only 2.2% of chronic pain, and these did not correlate with recurrence in our experience. Dr Sihoe: It’s not just pain, though. It’s a multitude of postoperative factors. How we treat the patient after surgery might have some bearing on future occurrence, don’t you think? Dr Imperatori: It could be, but we postoperatively recorded a pain VAS in all patients. We do not have a very high mean VAS score, and this did not correlate with recurrence in our experience. Postoperative pain treatment was usually with analgesic drugs usually per os ( paracetamol) and exceptionally with intravenous drugs, so I don’t think this could be the main point.
eComment. Innovation for minimally invasive surgical treatment of pneumothorax Authors: Pietro Bertoglio, Stylianos Korasidis and Marcello C. Ambrogi Dept of Surgical Medical Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy doi: 10.1093/icvts/ivv102 © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. I read the interesting article by Imperatori and his coworkers [1]. Pneumothorax can be considered as one of the most common diagnosis in general thoracic surgery wards, but the surgical approach may vary between single institutions. The videoassisted thoracoscopic surgery (VATS) approach is nowadays considered the gold standard, allowing a better aesthetic result and a more painless postoperative course [2], but intraoperative management of blebs/bullae and pleurodesis are reported in a heterogeneous way. Our institution has recently reported its experience [3] in pneumothorax surgical treatment with an innovative minimally invasive tool which uses radiofrequency
energy to make bullae collapse and preserve the integrity of the visceral pleura. This surgical instrument is very thin and flexible bringing two main advanges: firstly, it requires smaller incision than stapler devices, secondly it can easily reach all the parts of chest cavity. Moreover, the same tool might be used also to perform pleurodesis through electrocoagulation of intercostals arches. In our experience, we achieved a very low postoperative complication rate (1.4%) and recurrence rate (2.7%). A greater attention to improve minimally invasive surgery and a less traumatic approach towards lung parenchyma are key for the future development of pneumothorax surgical treatment. Although wider cohorts are needed to validate our good results, the use of new technologies may not only decrease recurrences rate and invasiveness but also dramatically reduce postoperative air leak, length of hospital stay and, as a consequence, costs for the health care system. Conflict of interest: none declared. References [1] Imperatori A, Rotolo N, Spagnoletti M, Festi L, Berizzi F, Di Natale D et al. Risk factors for postoperative recurrence of spontaneous pneumothorax treated by video-assisted thoracoscopic surgery Interact CardioVasc Thorac Surg 2015;20:647–653. [2] Baumann MH, Strange C, Heffner JE, Light R, Kirby TJ, Klein J et al. Management of spontaneous pneumothorax. An American College of Chest Physicians Delphi Consensus Statement. Chest 2001;119:590–602. [3] Ambrogi MC, Zirafa CC, Davini F, Giarratana S, Lucchi M, Fanucchi O et al. Transcollation® technique in the thoracoscopic treatment of primary spontaneous pneumothorax. Interact CardioVasc Thorac Surg 2015;20: 445–448.
eComment. A bicycle inner tube in a glass of water! Video-assisted thoracoscopic surgery for spontaneous pneumothorax and the submersion test Authors: Paolo Scanagatta, Stefano Sestini, Leonardo Duranti and Federico Piccioni Division of Thorac Surg and Department of Anesthesia, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy doi: 10.1093/icvts/ivv052 © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. We read with interest the well-written study by Imperatori et al. about risk factors for postoperative recurrence of spontaneous pneumothorax (SP) treated by videoassisted thoracoscopic surgery (VATS) [1]. Not surprisingly, the authors found a correlation between postoperative prolonged air leaks and recurrence of SP, which they attributed to the overlooking of leaking bullae, given that air leakage tests are sometimes difficult to interpret during VATS. We would like to comment on this. According to Naunheim and colleagues, the only independent predictive factor for the recurrence of SP is the failure to identify and resect blebs during surgery [2]. The key point is that the working space of VATS is very narrow, requiring the lung parenchyma to be held in an unnatural state to perform the submersion test correctly, and the evaluation of air leaks could be more effective when the lung is examined under a normal physiological state, i.e. fully inflated and without any mechanical pressure applied by the surgeon [3]. In fact, submersion test is similar to that when one is trying to find a hole in the inner tube of a bicycle wheel and performing this test on a lung during VATS is quite akin to submerging an inner tube in a glass of water. Therefore, after having performed a negative submersion test, we suggest checking air leaks using mechanical ventilator measurements before ending the surgical procedure. The ventilator test procedure could be as follow: 1) the ventilator setting is placed to volume-controlled modality, with two lung ventilation and at a fixed predefined tidal volume; 2) the evaluation is performed after having waited for the operated lung to re-inflate completely; 3) if there is an air-leakage >5% measured by the inhaled/exhaled tidal volume ratio, the submersion test must be repeated and the visceral pleural surface accurately re-checked to identify blebs or discontinuation of surgical suture-lines; 4) at the same time, it is easy to detect the presence of air leak looking at volume curve or at the pressure-volume loop. With a significant leak, the volume curve does not return to zero at the end of expiration but instead resets at the start of the next ventilator breath [4]. Similarly, the expiratory portion of the pressure-volume loop does not return to baseline in presence of a leak.
A. Imperatori et al. / Interactive CardioVascular and Thoracic Surgery
Regarding the second question, this is another key point. You are right, in the analysis of our data, three out of four female patients with recurrence had endometriosis, and in two of these, we were able to detect intraoperatively by inspection of the diaphragm the typical brown fenestration. These two patients underwent hormonal therapy. Unfortunately, just in one case we were able to show pathologically that this was a site of endometriosis. The other case was just necrotic tissue, probably because we were in the menstrual period of the patient. In conclusion, it’s very important to focus on a correct inspection of the diaphragm before performing VATS surgery for pneumothorax in young women. Dr G. Cardillo (Rome, Italy): I have a short question for you. All of us know that the key point for recurrence prevention is the pleurodesis, not the bullectomy. Recurrence rate showed 6%. In my opinion that is too high, so try to reconsider the partial pleurectomy, which seems not enough for recurrence prevention in light of your 6% recurrence rate. Can you comment on that? Dr Imperatori: You are right. This study enrolled patients until 2010, and we retrospectively evaluated our data. We are now considering performing, when possible, talc poudrage for pleurodesis. This could be the solution to avoid basal recurrence and to let the drainage for a shorter time. Moreover, it could reduce the postoperative air leakage that could be due to an incomplete resection of the bullae or when stapling lung resection falls on dystrophic tissue. Dr A. Sihoe (Hong Kong, China): Just two very quick questions. First point, you mentioned a lot of patients had recurrence quite late, and I think that’s something that we’re starting to realize all around the world. So, in the future, instead of just reporting a recurrence rate after an average of so many months, don’t you think it’s actually more appropriate that we do a survival analysis to study recurrences? The second question is: most studies on recurrence after surgery tend to focus on patient factors like female, age and also intraoperative factors. But I think points that we’re neglecting are the postoperative factors, how much pain the patient is in, what analgesia they’re given, how much suction we apply, is there an appearance of a rim of air after we remove the chest tubes? Did you consider looking at these factors? Dr Imperatori: For the first question, I agree with you. Late recurrence is very important because if we had completed our follow-up after four years, as reported in several studies, we would have lost 50% of recurrence in our centre, and we could show a 3% recurrence rate. For the suggested survival analysis, it could not be the right approach because recurrence is usually a rare event. The second point is pain. As I briefly showed you, we had 10% of ipsilateral chest wall dysaesthesia and only 2.2% of chronic pain, and these did not correlate with recurrence in our experience. Dr Sihoe: It’s not just pain, though. It’s a multitude of postoperative factors. How we treat the patient after surgery might have some bearing on future occurrence, don’t you think? Dr Imperatori: It could be, but we postoperatively recorded a pain VAS in all patients. We do not have a very high mean VAS score, and this did not correlate with recurrence in our experience. Postoperative pain treatment was usually with analgesic drugs usually per os ( paracetamol) and exceptionally with intravenous drugs, so I don’t think this could be the main point.
eComment. Innovation for minimally invasive surgical treatment of pneumothorax Authors: Pietro Bertoglio, Stylianos Korasidis and Marcello C. Ambrogi Dept of Surgical Medical Molecular Pathology and Critical Care, University of Pisa, Pisa, Italy doi: 10.1093/icvts/ivv102 © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. I read the interesting article by Imperatori and his coworkers [1]. Pneumothorax can be considered as one of the most common diagnosis in general thoracic surgery wards, but the surgical approach may vary between single institutions. The videoassisted thoracoscopic surgery (VATS) approach is nowadays considered the gold standard, allowing a better aesthetic result and a more painless postoperative course [2], but intraoperative management of blebs/bullae and pleurodesis are reported in a heterogeneous way. Our institution has recently reported its experience [3] in pneumothorax surgical treatment with an innovative minimally invasive tool which uses radiofrequency
energy to make bullae collapse and preserve the integrity of the visceral pleura. This surgical instrument is very thin and flexible bringing two main advanges: firstly, it requires smaller incision than stapler devices, secondly it can easily reach all the parts of chest cavity. Moreover, the same tool might be used also to perform pleurodesis through electrocoagulation of intercostals arches. In our experience, we achieved a very low postoperative complication rate (1.4%) and recurrence rate (2.7%). A greater attention to improve minimally invasive surgery and a less traumatic approach towards lung parenchyma are key for the future development of pneumothorax surgical treatment. Although wider cohorts are needed to validate our good results, the use of new technologies may not only decrease recurrences rate and invasiveness but also dramatically reduce postoperative air leak, length of hospital stay and, as a consequence, costs for the health care system. Conflict of interest: none declared. References [1] Imperatori A, Rotolo N, Spagnoletti M, Festi L, Berizzi F, Di Natale D et al. Risk factors for postoperative recurrence of spontaneous pneumothorax treated by video-assisted thoracoscopic surgery Interact CardioVasc Thorac Surg 2015;20:647–653. [2] Baumann MH, Strange C, Heffner JE, Light R, Kirby TJ, Klein J et al. Management of spontaneous pneumothorax. An American College of Chest Physicians Delphi Consensus Statement. Chest 2001;119:590–602. [3] Ambrogi MC, Zirafa CC, Davini F, Giarratana S, Lucchi M, Fanucchi O et al. Transcollation® technique in the thoracoscopic treatment of primary spontaneous pneumothorax. Interact CardioVasc Thorac Surg 2015;20: 445–448.
eComment. A bicycle inner tube in a glass of water! Video-assisted thoracoscopic surgery for spontaneous pneumothorax and the submersion test Authors: Paolo Scanagatta, Stefano Sestini, Leonardo Duranti and Federico Piccioni Division of Thorac Surg and Department of Anesthesia, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy doi: 10.1093/icvts/ivv052 © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. We read with interest the well-written study by Imperatori et al. about risk factors for postoperative recurrence of spontaneous pneumothorax (SP) treated by videoassisted thoracoscopic surgery (VATS) [1]. Not surprisingly, the authors found a correlation between postoperative prolonged air leaks and recurrence of SP, which they attributed to the overlooking of leaking bullae, given that air leakage tests are sometimes difficult to interpret during VATS. We would like to comment on this. According to Naunheim and colleagues, the only independent predictive factor for the recurrence of SP is the failure to identify and resect blebs during surgery [2]. The key point is that the working space of VATS is very narrow, requiring the lung parenchyma to be held in an unnatural state to perform the submersion test correctly, and the evaluation of air leaks could be more effective when the lung is examined under a normal physiological state, i.e. fully inflated and without any mechanical pressure applied by the surgeon [3]. In fact, submersion test is similar to that when one is trying to find a hole in the inner tube of a bicycle wheel and performing this test on a lung during VATS is quite akin to submerging an inner tube in a glass of water. Therefore, after having performed a negative submersion test, we suggest checking air leaks using mechanical ventilator measurements before ending the surgical procedure. The ventilator test procedure could be as follow: 1) the ventilator setting is placed to volume-controlled modality, with two lung ventilation and at a fixed predefined tidal volume; 2) the evaluation is performed after having waited for the operated lung to re-inflate completely; 3) if there is an air-leakage >5% measured by the inhaled/exhaled tidal volume ratio, the submersion test must be repeated and the visceral pleural surface accurately re-checked to identify blebs or discontinuation of surgical suture-lines; 4) at the same time, it is easy to detect the presence of air leak looking at volume curve or at the pressure-volume loop. With a significant leak, the volume curve does not return to zero at the end of expiration but instead resets at the start of the next ventilator breath [4]. Similarly, the expiratory portion of the pressure-volume loop does not return to baseline in presence of a leak.
