The best time for surgery on a patient with recurrent pneumothorax and undetectable culprit lesions is at the exact time air leakage is discovered: a case report
Matsumoto et al. Journal of Cardiothoracic Surgery
The best time for surgery on a patient with recurrent pneumothorax and undetectable culprit lesions is at the exact time air leakage is discovered: a case report
Yousuke Matsumoto 0
Yoshinobu Hata 0
Takashi Makino 0
Satoshi Koezuka 0
Hajime Otsuka 0
Keishi Sugino 1
Kazutoshi Isobe 1
Sakae Homma 1
Akira Iyoda 0
0 Division of Chest Surgery, Toho University School of Medicine , Tokyo , Japan
1 Division of Respiratory Medicine, Toho University School of Medicine , Tokyo , Japan
Background: One cause of recurrent spontaneous pneumothorax includes overlooking bullae during a previous surgery for pneumothorax; and the identification of the culprit lesions is necessary for prevention of recurrence. Case presentation: A 28-year-old man was referred to our hospital because of spontaneous right-sided pneumothorax. He underwent video-assisted thoracoscopic surgery, which did not reveal air leakage. The patient was subsequently seen at our hospital for 2 additional episodes of recurrent right-sided pneumothorax. At the third admission we observed intermittent air leakage while the patient was in the sitting position after chest drainage, and we performed surgery. An intraoperative submersion test showed air leakage dorsally from the pleural surface of S6 and a minute culprit lesion, which were not seen at the first operation and confirmed the leakage site. The area was ligated and coated with regenerated oxidized cellulose mesh and autologous blood. Conclusion: In cases of pneumothorax with repeated recurrence, the best time to perform surgery on the patient with undetectable culprit lesion is the exact time that air leakage is observed.
Recurrent pneumothorax; Video-assisted thoracoscopic surgery; Submersion test
Background
Video-assisted thoracoscopic surgery (VATS) has
become the standard operative approach for treating
spontaneous pneumothorax, because it is less invasive than
open thoracotomy. However, the recurrence rate of
pneumothorax after VATS is significantly higher [
1
].
One cause of recurrent spontaneous pneumothorax is
failure to identify bullae during a previous surgery for
pneumothorax; identification of the bullae is necessary
for prevention of recurrence. Herein, we describe a
patient with recurrent pneumothorax, for whom we were
able to use an intraoperative submersion test to identify
a minute culprit lesion, because we performed surgery at
the time air leakage was observed.
Case presentation
A 28-year-old man was referred to our hospital because
of right-sided spontaneous pneumothorax (Fig. 1). He
was an active smoker with a 10-year history of smoking
40 cigarettes a day, but otherwise his medical history
was unremarkable. A chest drainage tube was inserted.
After re-expansion of the lung, active air leakage was
not apparent. The right lung collapsed with the drainage
tube clamped, and VATS was performed. Thoracoscopic
examination revealed a few small bullae at the apex of
the right upper pulmonary lobe (Fig. 2). An
intraoperative submersion test did not reveal active air leakage.
Wedge resection was performed for the small bullae in
the right upper lobe. The staple line was ligated at both
ends and covered with regenerated oxidized cellulose
mesh and autologous blood.
Three months later, the patient was referred to our
hospital for recurrent right-sided pneumothorax. The air
leak disappeared after chest drainage was performed,
and an initial clamp test showed collapse of the lung.
However, a second clamp test did not result in collapsed
lung, and the patient was discharged.
One month after the second visit, the patient was
again referred to our hospital for recurrent
rightsided pneumothorax (Fig. 3). Because intermittent air
leakage was noticed with the patient in a seated
position after chest drainage, we performed surgery. An
intraoperative submersion test revealed air leakage
dorsally from the S6 pleural surface and a minute
culprit lesion (Fig. 4), which were not seen during the
first operation, confirmed the site of leakage. The
affected area was ligated and coated with regenerated
oxidized cellulose mesh and autologous blood. The
surgery was performed immediately, at the time that
air leakage was noted, and we were able to identify
the culprit lesion by examining the entire lung in a
study to water-seal.
Discussion
The recurrence rate of pneumothorax is significantly
higher following VATS than after open thoracotomy,
and has been reported to range from 4.1% to 11.5% [
1
].
Newly developed bullae around the suture line and
failure to identify bullae during surgery are thought to be
causes of recurrent pneumothorax. Kurihara et al.
reported that regenerated bullae near the suture line were
thought to result from the lung being picked up
with a stapler deeply and powerfully during
thoracoscopic surgery [
2
]. Therefore, reinforcement of the
visceral pleura around the staple line is used in
clinical practice [
3
].
Failure t (...truncated)