Thoracoscopic surgery under local anesthesia for high-risk intractable secondary spontaneous pneumothorax
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ORIGINAL ARTICLE
Thoracoscopic surgery under local anesthesia for high‑risk intractable secondary spontaneous pneumothorax Tetsuya Fukui1 · Kikuko Minami1 · Yusuke Wakatsuki1 · Tadashi Matsukura1 Received: 19 January 2020 / Accepted: 15 March 2020 © The Japanese Association for Thoracic Surgery 2020
Abstract Objectives To evaluate the outcomes of thoracoscopic surgery for intractable secondary spontaneous pneumothorax (SSP) under local anesthesia in high-risk patients and report intraoperative findings useful for identifying air leakage points. Methods We analyzed outcomes of 14 consecutive thoracoscopic operations under local anesthesia for high-risk SSP from 2015 to 2019. Suspicious lesions were determined based on intraoperative direct or indirect detections. Direct detection involved identifying pleural fistulas or air bubbles. Indirect detection involved finding thin and transparent bullae without any other suspicious lesions. Identifications of culprit lesions were confirmed by arrest or significant decrease in air leakage after surgical repair. All surgical repairs were followed by immediate single pleurodesis for a definitive cure and prevention of recurrence. Success was defined as the removal of the thoracic tube by surgical repair combined with immediate postoperative single pleurodesis. Results The main underlying pulmonary diseases were emphysema (n = 7), carcinoma (n = 3), interstitial pneumonia (IP) (n = 3), and nontuberculous mycobacterial infection (n = 1). A leakage point was identified in 13 cases (six on direct and seven on indirect detections). Success was achieved in nine cases (four on direct and five on indirect detections). Adverse events included one case of acute exacerbation of IP and one case of carbon dioxide narcosis. Conclusion Thoracoscopic surgery under local anesthesia can be the worthwhile definitive modality, among few remaining treatments, for highly fragile patients with SSP. Detecting air leakage directly and the presence of thin and transparent bullae without any other suspicious lesions can be clues for identifying culprit lesions. Keywords Secondary spontaneous pneumothorax · Video-assisted thoracic surgery · Thoracoscopic surgery · Local anesthesia · Awake thoracoscopic surgery
Introduction Management of secondary spontaneous pneumothorax (SSP) with prolonged air leakage is challenging. Most patients with SSP are elderly with comorbidities and tend to have poor performance status (PS). Surgical intervention is reported to be favorable for SSP [1–3]. Though general anesthesia management has been improving recently, there are concerns that some highly fragile patients with SSP can have difficulty in tracheal extubation after surgeries with prolonged positivepressure ventilation, which can exacerbate air leakage and * Tetsuya Fukui [email protected] 1
prevent pleural healing. Thoracoscopic surgery under local anesthesia can be the final definitive treatment modality for highly fragile patients with intractable SSP. However, only a small number o
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