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Interact CardioVasc Thorac Surg 2009;9:1003-1008. doi:10.1510/icvts.2009.216473 © 2009 European Association of Cardio-Thoracic Surgery
In patients with first-episode primary spontaneous pneumothorax is video-assisted thoracoscopic surgery superior to tube thoracostomy alone in terms of time to resolution of pneumothorax and incidence of recurrence?
a Brighton and Sussex Medical School, UK Received 11 July 2009; received in revised form 2 September 2009; accepted 9 September 2009
*Corresponding author. Tel.: +447515542899.
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed whether video-assisted thoracoscopic surgery (VATS) was justifiable for first-episode primary spontaneous pneumothorax (PSP). Altogether 183 papers were found using the reported search, of which nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that VATS has superior outcomes in terms of recurrence rates of pneumothorax (from 0 to 13% according to several studies for VATS vs. 22.8 to 42% for tube thoracostomy alone), duration of chest tube drainage (CTD) (4.56 vs.7.6 days) and mean hospital stay (from 2.4 to 7.8 days vs. 6 to 12 days for CTD) with first-episode PSP compared with conservative treatment. Additionally, even if VATS is associated with an average increased cost of $408, this is mitigated by the reduced length of stay and decreased pneumothorax recurrence, both resulting in a reduction of cost of 42% compared to conservative approach. These findings were not replicated in an article considering primary VATS (PV) vs. secondary VATS (SV) as the best treatment modality for PSP in children. Although the total treatment length of stay was significantly shorter for PV vs. SV (7.1±0.96 vs. 10.5±1.2, P=0.04), morbidity from recurrent pneumothorax after VATS occurred more frequently after PV than SV (4/14 vs. 0/20, P<0.05). In this article the observed recurrence rate was 54%. Performing PV on all patients with PSP would increase cost by $4010 per patient and require a recurrence rate of 72% or more to financially justify this approach, therefore, the increased morbidity and cost do not justify a strategy of PV blebectomy/pleurodesis in children with spontaneous pneumothorax (SP). Instead, secondary treatment is recommended. Lastly, two articles also examined the rate of recurrence of VATS compared to open thoracotomy (OT). The range was from 0 to 7.7% for OT vs. 10.3 to 13% for VATS, a non-statistical difference.
Key Words: Thoracic surgery; Video-assisted; VATS; Primary spontaneous pneumothorax; First-episode pneumothorax
A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].
In [patients with first episode primary spontaneous pneumothorax] is [video-assisted thoracoscopic surgery] superior to [tube thoracostomy alone] in terms of [time to resolution of pneumothorax and incidence of recurrence]?
A 19-year-old man presents at accident and emergency (A & E) with sudden onset shortness of breath. Clinical examination reveals signs consistent with a left-sided pneumothorax confirmed by chest X-ray. A diagnosis of primary spontaneous pneumothorax (PSP) is made and an intercostal drain is inserted successfully. You are aware of the high recurrence rate and long hospital admissions associated with conservative treatment and wonder whether a definitive surgical intervention using video-assisted thoracoscopic surgery (VATS) may be justified in the first instance. You decide to carry out a literature search for the evidence.
[exp pneumothorax/] AND [VATS.mp. OR exp Thoracic Surgery, Video-Assisted/] AND [first.mp OR primary.mp] Medline 1950 to May 2007 using OVID interface.
One hundred and eighty-three papers were found using the reported search. From these, nine papers were identified that provided the best evidence to answer the question. These are presented in Table 1.
In 2008, Chen et al. [2] conducted a retrospective chart review of 164 patients who underwent simple aspiration for first-episode PSP. Of these, 52 underwent subsequent treatment either via VATS (30 patients) or chest tube drainage (CTD) (22 patients) due to unsuccessful aspiration. They found that VATS, although more expensive than CTD by a mean of $408 per patient, provided a superior salvage technique with lower complication rates, shorter mean hospital stay (P=0.034) and reduced recurrence (P=0.038). Hirai et al. [3] assessed patients on admission via computed tomography (CT) to identify the presence of bulla and/or bleb and conducted a retrospective comparison between CTD, VATS and limited thoracotomy (LT). Recurrence rates with identified presence of bulla and/or bleb were 48%, compared to 20% when absent. They showed that patients undergoing VATS (62 cases) or LT (9 cases) had recurrence rates of 13% and 0%, respectively, compared to an average of 42% (97 cases) with CTD. Retrospective analysis by Chou et al. [4] in 2003, found that 90% of their 51 patients treated by VATS between 1997 and 2002 for PSP had blebs and that this was a likely cause of recurrence if treated conservatively. Average postoperative stay was 4 days for the 51 patients and, on 38 months follow-up, no recurrence or complication was found. This follows analysis of a protocol by Kim et al. [5] in 1998, who used high resolution CT (HRCT) to identify blebs as a surgical indication for VATS in a cohort of 61 patients. HRCT revealed blebs in 78% (48 patients) compared to only 11% (7 patients) with identified bullae using chest radiography. VATS was used in 94% (45 patients) with identified blebs, with comparatively better outcomes for observation duration prior to definitive surgical outcome, shorter mean hospital stay and decreased recurrence rate. Sawada et al. [6] performed a retrospective study of 281 patients diagnosed between 1989 and 2001, comparing outcomes for conservative CTD, VATS and open thoracotomy (OT). Of those treated for first episode PSP, recurrence rates were 54.7%, 10.3% and 7.7%, respectively. There was no statistical difference between recurrence rates of VATS and OT (P=0.15), though mean hospital stay was significantly shorter with VATS treatment [4.1 vs. 11.5 (P<0.001)]. VATS was also superior to OT in terms of low morbidity, low invasiveness, and cosmetic issues. Margolis et al. [7] in 2003 looked retrospectively at 156 patients treated by VATS with associated bleb resection between 1992 and 2001. The median age of presentation was 19 years (range 14–38) of whom 69% were male. Bleeding occurred in 23 patients, associated with bleb rupture. There were no postoperative air leaks and the mean hospital stay was 2.4±0.5 days. Follow-up ranged from 2 to 96 months (median 62 months) for which there were no recurrences on the index side. Torresini et al. [8] analysed 70 patients presenting with first-episode PSP, 35 of whom were treated with VATS and 35 by pleural drainage (PD). Following PD, prolonged air leaks occurred in four patients (11.4%), and eight patients (22.8%) had at least one recurrence, whereas with VATS this was two patients (5.7%) and one patient (2.8%), respectively. Mean time for drainage and hospitalization was, respectively, 9 and 12 days in patients with PD against 3.9 and 6 days for those using VATS. Average management costs per patients including hospitalization was calculated at $2750.00 per patient following PD compared with $1925.00 following VATS. Schramel et al. [9] undertook a retrospective cost-benefit analysis of conservative treatment vs. VATS, comparing 112 patients treated by conservative therapy during 1985–1989 with 97 patients treated by VATS during 1991–1994. Complications were found to be lower in the VATS group and cost 42% less than conservative treatment. They also found that if patients with spontaneous pneumothorax (SP) had been treated with simple talc pleurodesis under thoracoscopy, this would have resulted in an additional 62% reduction in the costs calculated for patients with VATS. Qureshi et al. [10] undertook a retrospective analysis to assess the benefit of primary VATS (PV) compared to secondary VATS (SV) for PSP in 51 children. Non-operative treatment was attempted in 37, of whom 20 recurred and thus required SV. PV was performed in 14. Total treatment length of stay was significantly shorter for PV vs. SV (7.1±0.96 vs. 10.5±1.2, P=0.04). However, morbidity from recurrent pneumothorax after VATS occurred more frequently after PV than SV (4/14 vs. 0/20, P<0.05). Performing PV on all patients with SP would also increase cost by $4010 per patient. Morimoto et al. [11] addressed the optimal strategy for PSP in young men. They developed a decision analysis model using a Markov model. This is an analytic structure that tracks the clinical events occurring in a hypothetical cohort of patients in various scenarios over time. Considering that benign disease like PSP affect patients' daily life but not survival, results were expressed in terms of quality adjusted life expectancy (QALE) in months. During a 1-year follow-up after the initial treatment the QALEs for thoracoscopic surgery were 9.49 months, 9.47 months for pleurodesis and 7.8 for PD, respectively. Morimoto et al. [12] developed the concepts already expressed in the first publication further. They addressed the effect of different timings for surgery on health status, costs and cost-effectiveness. Thirty-six percent of patients treated with single PD and 31% of those treated with two PD underwent VATS at 4 months follow-up. The percentages increase at 59 and 45%, respectively, at 24 months follow-up. Mean length of stay is 7.4 days for initial VATS and drainage twice strategy and 7.3 days for drainage once strategy. Costs were higher for initial VATS at US $6556, but when adjusted according to the quality adjusted life year (QALY) they became US $30,564 for VATS at the second episode of PSP and US $29,915 for surgery at the third episode of PSP. Although there is no absolute standard for acceptable incremental costs, those with a QALY of less than US 35,000–50,000 are considered acceptable in the US.
In first episodes of PSP, observation and simple aspiration are the current established first line therapies, whereas VATS is the treatment of choice for recurrent episodes. However, several retrospective studies have shown, unanimously, that VATS has superior outcomes in terms of recurrence rates, duration of CTD and mean hospital stay with first episode PSP. Additionally, the reduced length of stay and decreased recurrence mitigates the increased cost associated with VATS.
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Abstract
1. Introduction