NEW IDEAS – THORACIC
Interactive CardioVascular and Thoracic Surgery 20 (2015) 445–448 doi:10.1093/icvts/ivu431 Advance Access publication 26 December 2014
Transcollation® technique in the thoracoscopic treatment of primary spontaneous pneumothorax Marcello Carlo Ambrogi, Carmelina Cristina Zirafa*, Federico Davini, Silvia Giarratana, Marco Lucchi, Olivia Fanucchi, Franca Melfi and Alfredo Mussi Department of Surgical Medical Molecular and Critical Area Pathology, Thoracic Surgery Unit, University of Pisa, Pisa, Italy * Corresponding author. Department of Surgical Medical Molecular and Critical Area Pathology, Thoracic Surgery Unit, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy. Tel: +39-050-995211; fax: +39-050-577239; e-mail: [email protected] (C. Zirafa). Received 19 June 2014; received in revised form 9 November 2014; accepted 18 November 2014
Abstract OBJECTIVES: The already low invasiveness of the thoracoscopic treatment of spontaneous pneumothorax may be further reduced by the transcollation® technique. Herein, we report our further experience with a new device, to coagulate blebs and bullae, compared with contrast to endostapler resection. METHODS: Data of patients with recurrent or persistent spontaneous pneumothorax, who underwent thoracoscopic treatment, were prospectively collected and reviewed. Those with blebs or bullae (Stages III and IV in accordance with Vanderschueren’s classification) were treated with a new device, based on coupling saline solution perfusion with radiofrequency energy. The combination of fluid with radiofrequency allows the sealing of tissue, avoiding charring or burning. Most operations were performed through two 1-cm incisions only. RESULTS: From 2005 to 2010, 73 patients were treated. These were 59 males (80.8%) and 14 females (19.2%), with a mean age of 27.9 years [standard deviation (SD): 11.7]. Forty-three patients underwent general anaesthesia with selective intubation, 9 awake epidural anaesthesia and 21 spontaneous breathing anaesthesia with laryngeal mask. The mean operation time was 31 min (SD: 10.2). The median postoperative drainage period and hospital stay were 2 days (range of 1–11) and 3 days (range of 2–11), respectively. Prolonged air leak occurred in 1 patient (1.4%). Over a mean follow-up period of 60 months (SD: 22.5), two recurrences (2.7%) were reported. CONCLUSIONS: The transcollation® technique by cold coagulation of blebs and bullae seems to be effective in the treatment of primary spontaneous pneumothorax. Owing to its potential advantages, it appears to be particularly suitable to be associated with awake epidural and LMA anaesthesia. Keywords: Spontaneous pneumothorax • Thoracoscopy • Video-assisted thoracic surgery • Surgical treatment • Coagulation • New technology
INTRODUCTION The main goals of any surgical research should be to increase the efficacy of surgical procedures and to reduce their invasiveness. In the past two decades, video-assisted thoracic surgery (VATS) has clearly achieved both goals in a variety of thoracic procedures, often expanding indications for surgical treatment. One of these paradigmatic cases is the treatment of primary spontaneous pneumothorax (PSP). There is now a general consensus to treat persistent or recurrent PSP by VATS and, in case of blebs or bullae, to perform stapled bullectomy [1–4]. To further reduce the invasiveness and, above all, the costs of VATS, recent papers have reported on the use of electrosurgical or laser-ablation methods for treatment of spontaneous pneumothorax, in opposition to endostapler resection [5–8]. We also reported, in a previous paper, our preliminary experience with transcollation®
technology (previously called ‘cold coagulation’), showing encouraging results [9]. Herein, we report our further experience with this technique, as well as its long-term results.
MATERIALS AND METHODS We prospectively collected the data of all patients with PSP admitted to our division. The selection criteria of patients treated with the transcollation® technique were as follows: persistent Stage I occurrence or repeated PSP; Stage III/IV blebs or bullae according to Vanderschueren’s classification. The first 10 cases were excluded in order to avoid interference in the learning curve. The primary aims of the study were to confirm the feasibility, safety and operative advantages of the procedure. The secondary
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
NEW IDEAS
Cite this article as: 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;20:445–8.
446
M.C. Ambrogi et al. | Interactive CardioVascular and Thoracic Surgery
objective was to assess its efficacy over the long term; thus, only patients with a minimum follow-up of 24 months were included.
Device The device we utilized to perform the transcollation® technique is a 5-mm endoscopic instrument called EndoFB 3.0 Floating Ball (Salient Surgical Technologies Corporate, Portsmouth, NH). It is widely utilized for liver resections and allows coagulation of blebs and bullae without charring or scar formation when placed into contact with tissue (Fig. 1). This is a saline-cooled radiofrequencypowered device that is connected to a standard operating theatre electrosurgical generator. The coagulation power is typically set to 80–90 W. A sterile 0.9% saline solution bag is connected to the irrigation tubing and adjusted for a drip rate of 4–8 cc/min. The device conducts radiofrequency energy from the generator to the electrode tip, where continuous low-volume saline irrigation cools the contact interface with the lung tissue, keeping surface temperature at 100°C. This avoids the eschar and char formation that occurs with standard electrocautery devices. The thermal energy results in heat denaturation of protein in the wall of blebs and bullae, thereby shrinking these blebs and bullae at their bases, and welding their walls to the underlying lung parenchyma. This phenomenon is called transcollation®. Moreover, vessels and bronchioli afferent to the bulla may be sealed.
Technique The procedure starts out like a standard thoracoscopic procedure, and is performed under general anaesthesia and single lung ventilation, awake epidural anaesthesia or spontaneously breathing laryngeal mask anaesthesia (LMA), based on the experience of the anaesthesiologist. During LMA anaesthesia, after induction by intravenous infusion of propofol, a laryngeal mask was positioned. Then general inhalatory anaesthesia was performed with sevoflurane. No muscle relaxants were used throughout the procedure, thereby allowing the patient to maintain spontaneous breathing [10]. Two small incisions are made in the axillary triangle: one for the 5-mm thoracoscopic camera, and the other for a 5-mm thoracoscopic instrument. In most cases, if the patients had already a pleural drainage, the chest tube wound was used as one of the two surgical incisions. After exploration, patients with blebs or small bullae, ranging from 5 to 30 mm (Stage III/IV according to Vanderschueren’s classification), undergo treatment with the transcollation® technique. It consists of ablation with the Floating Ball, for a few seconds, over the bulla until the bulla’s walls shrink over its base and then a little bit around the base itself (Fig. 2).
Figure 1: EndoFB 3.0 Floating Ball device, tip and handle.
Then, after instillation of saline solution in the pleural space, the lung was inflated to test for air leak. With the same device, using the spray mode in order to block saline solution perfusion, it is then possible to perform pleural scarring of the upper hemithorax, as we generally do in the standard technique, after staple bullectomy (Fig. 3). At the end of the procedure, two pleural drainages are inserted through the same operative incisions.
Data collection and follow-up Operation time, intraoperative and postoperative complications ( prolonged air leak was set over 7 days), postoperative drainage period and hospital stay were prospectively recorded. The followup after discharge consisted of an outpatient visit with a new chest X-ray at 30 days, 1 year and 2 years, and then it was by phone.
RESULTS From 2005 to 2010, 73 patients were treated, these being 59 males (80.8%) and 14 females (19.2%), with a mean age of 27.9 years [standard deviation (SD): 11.7]. Forty-three patients underwent general anaesthesia with selective intubation, 9 awake epidural anaesthesia and 21 spontaneously breathing anaesthesia with laryngeal mask airway. At the end of the procedure, no air leak was noted. The mean operation time was 31 min (SD: 10.2). There was no conversion to thoracotomy in any of the patients. The median postoperative drainage period and hospital stay were 2 days (range of 1–11) and 3 days (range of 2–11), respectively. Prolonged air leak occurred in 1 patient (1.4%), who required reoperation by axillary thoracotomy to suture a tear in the treated area. Over a mean follow-up period of 60 months (SD: 22.5), 2 patients (2.7%) developed a recurrence, after 29 and 37 days, respectively (Table 1). One was treated with pleural drainage, while the second underwent surgical revision by VATS, during which only a few weak pleural adhesions were noted and, notwithstanding that no air leak was revealed, a stapler resection of the previously treated apical sclerotic area of the upper lobe was performed. Pathological examination revealed subpleural dystrophic bullae and fibrosis, thus suggesting an incomplete coagulation of the previous bullous dystrophic area.
DISCUSSION Video-assisted thoracoscopy is the surgical approach of first choice for the treatment of pneumothorax. During VATS, the
447
NEW IDEAS
M.C. Ambrogi et al. | Interactive CardioVascular and Thoracic Surgery
Figure 2: Transcollation technique: setting of perfusion, the tip in contact with the bulla, and coagulation of the bulla and around its base.
Figure 3: Pleurodesis procedure by hot coagulation (without perfusion) of the parietal pleura over the first eight costal arches.
Table 1: Clinical and surgical characteristics Number of patients Male:female Mean age (range) Operation time (range) Drainage period (range) Hospitalization (range) Prolonged air leak (rate) Recurrence (rate)
73 59:14 27.9 years (15–59) 31 min (19–78) 2.3 days (1–11) 3.1 days (2–11) 1 (1.4%) 2 (2.7%)
majority of surgeons perform resection of blebs or bullae by means of an endostapler, although in the last few years various techniques have been employed with the aim to overcome the limits of this procedure. In fact, the utilization of an endostapler may produce greater postoperative pain, because a larger intercostal incision is necessary to introduce the device into the
thoracic cavity, with consequent greater trauma. Moreover, resection by stapler may be difficult in the event of a bulla positioned in the pulmonary fissure or on the mediastinal surface of the lung. After resection of bullae or blebs, about 2–9.5% of patients have presented with prolonged postoperative air leak, likely caused by the outflow of air through the suture, while ipsilateral recurrence is seen to be 5%, and is induced by the regrowth of bullae around the staple line [11–14]. Therefore, to treat the bullae in patients with pneumothorax, some authors have developed electro-ablation or laser-ablation (argon laser, carbon dioxide laser or Nd:YAG laser) technique, achieving in the last few years satisfactory results with regard to operation times and postoperative pain. Nevertheless, these procedures have seen higher rates of prolonged air leak and recurrence, caused by damage of pulmonary tissue during the ablation, in particular in treatment of pulmonary lesions of 2 cm or more in diameter. One of these techniques was reported in 2005 by Sawabata et al. [15] , who used an electrosurgical unit with a ball-shaped tip of 8 mm (M-tip) connected to a standard electrosurgical unit, to coagulate residual blebs and bullae after stapler resection of the involved lesions. They reported a low rate of postoperative relapse, but a higher rate of prolonged air leak in the group of patients treated by M-tip electro-ablation, in particular in cases of lesions >2 cm in diameter, than in those patients who underwent only stapled resection of pneumocysts (9.8% vs 2.9%). Moreover, several studies regarding laser ablation of pulmonary bullae have reported a high incidence of air leaks, resulting from the perforation of lesions when a laser was used during the surgical procedure [7–9, 11–17]. In the experience of Hazama’s group, better results were obtained, probably because bullous lesions of
Interactive CardioVascular and Thoracic Surgery 20 (2015) 445–448 doi:10.1093/icvts/ivu431 Advance Access publication 26 December 2014
Transcollation® technique in the thoracoscopic treatment of primary spontaneous pneumothorax Marcello Carlo Ambrogi, Carmelina Cristina Zirafa*, Federico Davini, Silvia Giarratana, Marco Lucchi, Olivia Fanucchi, Franca Melfi and Alfredo Mussi Department of Surgical Medical Molecular and Critical Area Pathology, Thoracic Surgery Unit, University of Pisa, Pisa, Italy * Corresponding author. Department of Surgical Medical Molecular and Critical Area Pathology, Thoracic Surgery Unit, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy. Tel: +39-050-995211; fax: +39-050-577239; e-mail: [email protected] (C. Zirafa). Received 19 June 2014; received in revised form 9 November 2014; accepted 18 November 2014
Abstract OBJECTIVES: The already low invasiveness of the thoracoscopic treatment of spontaneous pneumothorax may be further reduced by the transcollation® technique. Herein, we report our further experience with a new device, to coagulate blebs and bullae, compared with contrast to endostapler resection. METHODS: Data of patients with recurrent or persistent spontaneous pneumothorax, who underwent thoracoscopic treatment, were prospectively collected and reviewed. Those with blebs or bullae (Stages III and IV in accordance with Vanderschueren’s classification) were treated with a new device, based on coupling saline solution perfusion with radiofrequency energy. The combination of fluid with radiofrequency allows the sealing of tissue, avoiding charring or burning. Most operations were performed through two 1-cm incisions only. RESULTS: From 2005 to 2010, 73 patients were treated. These were 59 males (80.8%) and 14 females (19.2%), with a mean age of 27.9 years [standard deviation (SD): 11.7]. Forty-three patients underwent general anaesthesia with selective intubation, 9 awake epidural anaesthesia and 21 spontaneous breathing anaesthesia with laryngeal mask. The mean operation time was 31 min (SD: 10.2). The median postoperative drainage period and hospital stay were 2 days (range of 1–11) and 3 days (range of 2–11), respectively. Prolonged air leak occurred in 1 patient (1.4%). Over a mean follow-up period of 60 months (SD: 22.5), two recurrences (2.7%) were reported. CONCLUSIONS: The transcollation® technique by cold coagulation of blebs and bullae seems to be effective in the treatment of primary spontaneous pneumothorax. Owing to its potential advantages, it appears to be particularly suitable to be associated with awake epidural and LMA anaesthesia. Keywords: Spontaneous pneumothorax • Thoracoscopy • Video-assisted thoracic surgery • Surgical treatment • Coagulation • New technology
INTRODUCTION The main goals of any surgical research should be to increase the efficacy of surgical procedures and to reduce their invasiveness. In the past two decades, video-assisted thoracic surgery (VATS) has clearly achieved both goals in a variety of thoracic procedures, often expanding indications for surgical treatment. One of these paradigmatic cases is the treatment of primary spontaneous pneumothorax (PSP). There is now a general consensus to treat persistent or recurrent PSP by VATS and, in case of blebs or bullae, to perform stapled bullectomy [1–4]. To further reduce the invasiveness and, above all, the costs of VATS, recent papers have reported on the use of electrosurgical or laser-ablation methods for treatment of spontaneous pneumothorax, in opposition to endostapler resection [5–8]. We also reported, in a previous paper, our preliminary experience with transcollation®
technology (previously called ‘cold coagulation’), showing encouraging results [9]. Herein, we report our further experience with this technique, as well as its long-term results.
MATERIALS AND METHODS We prospectively collected the data of all patients with PSP admitted to our division. The selection criteria of patients treated with the transcollation® technique were as follows: persistent Stage I occurrence or repeated PSP; Stage III/IV blebs or bullae according to Vanderschueren’s classification. The first 10 cases were excluded in order to avoid interference in the learning curve. The primary aims of the study were to confirm the feasibility, safety and operative advantages of the procedure. The secondary
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
NEW IDEAS
Cite this article as: 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;20:445–8.
446
M.C. Ambrogi et al. | Interactive CardioVascular and Thoracic Surgery
objective was to assess its efficacy over the long term; thus, only patients with a minimum follow-up of 24 months were included.
Device The device we utilized to perform the transcollation® technique is a 5-mm endoscopic instrument called EndoFB 3.0 Floating Ball (Salient Surgical Technologies Corporate, Portsmouth, NH). It is widely utilized for liver resections and allows coagulation of blebs and bullae without charring or scar formation when placed into contact with tissue (Fig. 1). This is a saline-cooled radiofrequencypowered device that is connected to a standard operating theatre electrosurgical generator. The coagulation power is typically set to 80–90 W. A sterile 0.9% saline solution bag is connected to the irrigation tubing and adjusted for a drip rate of 4–8 cc/min. The device conducts radiofrequency energy from the generator to the electrode tip, where continuous low-volume saline irrigation cools the contact interface with the lung tissue, keeping surface temperature at 100°C. This avoids the eschar and char formation that occurs with standard electrocautery devices. The thermal energy results in heat denaturation of protein in the wall of blebs and bullae, thereby shrinking these blebs and bullae at their bases, and welding their walls to the underlying lung parenchyma. This phenomenon is called transcollation®. Moreover, vessels and bronchioli afferent to the bulla may be sealed.
Technique The procedure starts out like a standard thoracoscopic procedure, and is performed under general anaesthesia and single lung ventilation, awake epidural anaesthesia or spontaneously breathing laryngeal mask anaesthesia (LMA), based on the experience of the anaesthesiologist. During LMA anaesthesia, after induction by intravenous infusion of propofol, a laryngeal mask was positioned. Then general inhalatory anaesthesia was performed with sevoflurane. No muscle relaxants were used throughout the procedure, thereby allowing the patient to maintain spontaneous breathing [10]. Two small incisions are made in the axillary triangle: one for the 5-mm thoracoscopic camera, and the other for a 5-mm thoracoscopic instrument. In most cases, if the patients had already a pleural drainage, the chest tube wound was used as one of the two surgical incisions. After exploration, patients with blebs or small bullae, ranging from 5 to 30 mm (Stage III/IV according to Vanderschueren’s classification), undergo treatment with the transcollation® technique. It consists of ablation with the Floating Ball, for a few seconds, over the bulla until the bulla’s walls shrink over its base and then a little bit around the base itself (Fig. 2).
Figure 1: EndoFB 3.0 Floating Ball device, tip and handle.
Then, after instillation of saline solution in the pleural space, the lung was inflated to test for air leak. With the same device, using the spray mode in order to block saline solution perfusion, it is then possible to perform pleural scarring of the upper hemithorax, as we generally do in the standard technique, after staple bullectomy (Fig. 3). At the end of the procedure, two pleural drainages are inserted through the same operative incisions.
Data collection and follow-up Operation time, intraoperative and postoperative complications ( prolonged air leak was set over 7 days), postoperative drainage period and hospital stay were prospectively recorded. The followup after discharge consisted of an outpatient visit with a new chest X-ray at 30 days, 1 year and 2 years, and then it was by phone.
RESULTS From 2005 to 2010, 73 patients were treated, these being 59 males (80.8%) and 14 females (19.2%), with a mean age of 27.9 years [standard deviation (SD): 11.7]. Forty-three patients underwent general anaesthesia with selective intubation, 9 awake epidural anaesthesia and 21 spontaneously breathing anaesthesia with laryngeal mask airway. At the end of the procedure, no air leak was noted. The mean operation time was 31 min (SD: 10.2). There was no conversion to thoracotomy in any of the patients. The median postoperative drainage period and hospital stay were 2 days (range of 1–11) and 3 days (range of 2–11), respectively. Prolonged air leak occurred in 1 patient (1.4%), who required reoperation by axillary thoracotomy to suture a tear in the treated area. Over a mean follow-up period of 60 months (SD: 22.5), 2 patients (2.7%) developed a recurrence, after 29 and 37 days, respectively (Table 1). One was treated with pleural drainage, while the second underwent surgical revision by VATS, during which only a few weak pleural adhesions were noted and, notwithstanding that no air leak was revealed, a stapler resection of the previously treated apical sclerotic area of the upper lobe was performed. Pathological examination revealed subpleural dystrophic bullae and fibrosis, thus suggesting an incomplete coagulation of the previous bullous dystrophic area.
DISCUSSION Video-assisted thoracoscopy is the surgical approach of first choice for the treatment of pneumothorax. During VATS, the
447
NEW IDEAS
M.C. Ambrogi et al. | Interactive CardioVascular and Thoracic Surgery
Figure 2: Transcollation technique: setting of perfusion, the tip in contact with the bulla, and coagulation of the bulla and around its base.
Figure 3: Pleurodesis procedure by hot coagulation (without perfusion) of the parietal pleura over the first eight costal arches.
Table 1: Clinical and surgical characteristics Number of patients Male:female Mean age (range) Operation time (range) Drainage period (range) Hospitalization (range) Prolonged air leak (rate) Recurrence (rate)
73 59:14 27.9 years (15–59) 31 min (19–78) 2.3 days (1–11) 3.1 days (2–11) 1 (1.4%) 2 (2.7%)
majority of surgeons perform resection of blebs or bullae by means of an endostapler, although in the last few years various techniques have been employed with the aim to overcome the limits of this procedure. In fact, the utilization of an endostapler may produce greater postoperative pain, because a larger intercostal incision is necessary to introduce the device into the
thoracic cavity, with consequent greater trauma. Moreover, resection by stapler may be difficult in the event of a bulla positioned in the pulmonary fissure or on the mediastinal surface of the lung. After resection of bullae or blebs, about 2–9.5% of patients have presented with prolonged postoperative air leak, likely caused by the outflow of air through the suture, while ipsilateral recurrence is seen to be 5%, and is induced by the regrowth of bullae around the staple line [11–14]. Therefore, to treat the bullae in patients with pneumothorax, some authors have developed electro-ablation or laser-ablation (argon laser, carbon dioxide laser or Nd:YAG laser) technique, achieving in the last few years satisfactory results with regard to operation times and postoperative pain. Nevertheless, these procedures have seen higher rates of prolonged air leak and recurrence, caused by damage of pulmonary tissue during the ablation, in particular in treatment of pulmonary lesions of 2 cm or more in diameter. One of these techniques was reported in 2005 by Sawabata et al. [15] , who used an electrosurgical unit with a ball-shaped tip of 8 mm (M-tip) connected to a standard electrosurgical unit, to coagulate residual blebs and bullae after stapler resection of the involved lesions. They reported a low rate of postoperative relapse, but a higher rate of prolonged air leak in the group of patients treated by M-tip electro-ablation, in particular in cases of lesions >2 cm in diameter, than in those patients who underwent only stapled resection of pneumocysts (9.8% vs 2.9%). Moreover, several studies regarding laser ablation of pulmonary bullae have reported a high incidence of air leaks, resulting from the perforation of lesions when a laser was used during the surgical procedure [7–9, 11–17]. In the experience of Hazama’s group, better results were obtained, probably because bullous lesions of
