Long-term results after tetracycline pleurodesis in spontaneous pneumothorax

doi:10.1016/0003-4975(92)90377-G

The Annals of Thoracic Surgery

Volume 53, Issue 6, June 1992, Pages 1015-1017

https://doi.org/10.1016/0003-4975(92)90377-G Get rights and content

Abstract

From 1979 to 1988 483 patients were admitted with primary spontaneous pneumothorax. All patients underwent thoracoscopy to identify the cause of pneumothorax. Chemical pleurodesis with instillation of tetracycline was performed if cysts less than 2 cm in diameter were found. If larger cysts were identified the patient underwent thoracotomy. In 93 patients with cysts larger than 2 cm the recurrence rate after thoracotomy was 4%. In 390 patients treated with intrapleural instillation of tetracycline, the recurrence rate was 16%. Fifty percent of the recurrences occurred within 30 days. The cause of recurrence in 42 patients (69%) was cysts missed at the initial thoracoscopy. This study has demonstrated that thoracoscopy is a reliable and safe method for selection of patients for chemical pleurodesis. It is, however, necessary that the thoracoscopy is meticulous to avoid recurrence from missed cysts.

References (11)

WG Gobbel et al.
Spontaneous pneumothorax
J Thorac Cardiovasc Surg
(1963)
U Wied et al.
Tetracycline versus silver nitrate pleurodesis in spontaneous pneumothorax
J Thorac Cardiovasc Surg
(1983)
GH Almassi et al.
Chemical pleurodesis in the presence of persistent air leak
Ann Thorac Surg
(1989)
VM Voge et al.
Spontaneous pneumothorax in the USAF aircrew population: a retrospective study
Aviat Space Environ Med
(1986)
AG Watt
Spontaneous pneumothorax. A review of 210 consecutive admissions to Royal Perth Hospital
Med J Austr
(1978)

There are more references available in the full text version of this article.

Cited by (53)

Risk factors for recurrent spontaneous pneumothorax: A population level analysis
2022, American Journal of Surgery
Citation Excerpt :
In this study, we are unable to tell what agent was used in the patients treated with chemical pleurodesis (tetracycline, minocycline, talc, etc.). The rates of recurrence after chemical pleurodesis reported in our work were in line or lower than that reported in randomized control trials and non-randomized studies evaluating the efficacy of prophylactic chemical pleurodesis after first-time episode of spontaneous pneumothorax.9,25–27 Lastly, we focused on the rate and risk factors for recurrent episodes of spontaneous pneumothorax as this may have the greatest clinical relevance.
We sought to determine the rate and risk factors of recurrent spontaneous pneumothorax in a diverse population.
Cohort study using the California Public Discharge Data file (1995–2010). We identified patients with first-time spontaneous pneumothorax. The primary outcome was recurrent pneumothorax. Associations with clinical, patient, and hospital characteristics were assessed using Cox regression analysis.
Among 14,609 patients with a first-time episode of spontaneous pneumothorax, 26.2% developed a recurrence. Risk factors included age <35 (Hazard Ratio [HR] 1.24 95%-Confidence Interval [CI] 1.14–1.36), Asian race (HR 1.24, CI 1.13–1.37), and tube thoracostomy (HR 1.2, CI 1.15–1.31). Mechancial pleurodesis (HR 0.37 CI 0.31–0.45) was superior to chemical pleurodesis (HR 0.71 CI 0.58–0.86) in reducing recurrence risk.
The risk of recurrent pneumothorax is greatest in patients age <35, Asians, and those requiring a tube thoracostomy. The risks of operative intervention should be balanced against patient risk for recurrence.
Efficacy of tigecycline pleurodesis: A comparative experimental study
2011, Journal of Surgical Research
Citation Excerpt :
In the mid 1960s, intrapleural instillation of tetracycline combined with chest drainage was the preferred method of chemical pleurodesis, mainly for patients with malignant pleural effusions [1, 2] and for recurrent pneumothorax [3–5].
We investigated whether tigecycline (TIGE) is more effective than talc in inducing pleurodesis in rabbits.
Fifty-six New Zealand rabbits were utilized in a two-phase study: Effects at 14 d (phase I) and at 28 d (phase II) were assessed. Saline solution (SAL n = 3), talc slurry (TALC 200 mg/kg, n = 5), and TIGE at different concentrations (mg/kg): TIGE0.5 (n = 5); TIGE1 (n = 5); TIGE3 (n = 5); TIGE25 (n = 5); TIGE50 (n = 5) were randomly injected, for each phase, through a right chest drainage. TIGE0.5 and TIGE1 were ineffective during phase I and were thus excluded from further investigation. At post mortem examination, pleurodesis was graded grossly and microscopically by three observers blinded to treatment groups.
Phase I: pleurodesis was more effective in TIGE25 and TIGE50 (P < 0.001); TALC was better than TIGE0.5 (P < 0.001), and TIGE1 (P = 0.49), macroscopically. Pleural thickness was significantly higher in TIGE25 compared with SAL, TALC, TIGE0.5, TIGE1, and TIGE3 (P < 0.01). No significant differences were evident between TALC and TIGE3, both macroscopically (P = 0.90) and microscopically (inflammation P = 0.99, fibrosis P = 0.96, pleural thickness P = 0.99). Phase II: better effectiveness of TIGE50 compared with all other groups (P < 0.001) except TIGE 25 (P = 0.29); results similar to phase I for TALC and TIGE3 (P = 0.99), macroscopically. Microscopically greater inflammation in TALC compared with TIGE3 (P < 0.05) and in TIGE50 to TIGE3 (P = 0.05). Significant complications occurred in all TIGE50 group. One of TIGE25 and one of TIGE50 died of respiratory distress and of right hemothorax+ascites, respectively.
Intrapleural TIGE3 mg/kg is as effective as talc in inducing pleurodesis in rabbits. The intrapleural TIGE toxicity threshold was reached at TIGE25 mg/kg concentration.
Pneumothorax, bullous disease, and emphysema
2010, Surgical Clinics of North America
Citation Excerpt :
In addition, there is concern about the long-term consequences of leaving foreign material (talc crystals) in the chest cavity in young patients. Intrapleural injection of tetracycline alone is less effective and has been associated with recurrence rates of 16%.26 Injection of tetracycline or doxycycline can be painful and it is important to premedicate patients with analgesics.
Prediction of recurrent spontaneous pneumothorax: CT scan findings versus management features
2007, Respiratory Medicine
Citation Excerpt :
Indeed, the recurrence rate of pneumothorax after surgical intervention is far less than after medical pleurodesis.20,22–24
To assess the association between primary spontaneous pneumothorax (PSP) recurrence and pulmonary CT scan findings, and other variables pertaining to clinical presentation and management.
Consecutive patients hospitalized for the first episode of PSP and treated by various strategies including chest tube or pleurocatheter drainage and, in persistent pneumothorax, by chemical or surgical pleurodesis. All patients had a pulmonary CT scan examination in the week following hospital discharge in order to calculate a score combining distribution, number and size of dystrophic pulmonary abnormalities. This score as well as other pertinent clinical and therapeutic parameters were compared between patients who ultimately experienced PSP recurrence and those who did not.
Eighty patients (mean age: 27±7 yr) were admitted for PSP and had a chest drainage with either a drain or pleurocatheter. Chest drainage and hospitalization durations were 4.7±3.2 and 6.2±3.5 days, respectively. Sixteen patients required chemical pleurodesis. Dystrophic bullae were present in CT scans in 72.5% patients. After a mean follow up of 34±20 months, 15 out of the 80 patients (19%) had a PSP recurrence. Multivariate statistical analysis disclosed the use of pleurocatheter ( $OR = 5$ ; 95% CI: 1.4–20; $P = 0.02$ ) and of chemical pleurodesis ( $OR = 8$ ; 95% CI: 1.5–47; $P = 0.015$ ) as independent predictors of PSP recurrence. The severity of dystrophic lesions inferred from the dystrophic score was not statistically associated with the risk of recurrence.
Dystrophic lesions are frequently present in PSP. They are not associated with an increased risk of recurrence.
Video-assisted thorascopic surgery for spontaneous idiopathic pneumothorax
2004, Cirugia Espanola
Evaluar los resultados inmediatos de la toracoscopia videoasistida para el tratamiento del neumotórax espontáneo primario y su resultado a largo plazo.
Se realiza un estudio retrospectivo con un seguimiento a largo plazo en el que se incluyó a 88 pacientes consecutivos que fueron intervenidos mediante toracoscopia videoasistida por neumotórax espontáneo primario desde enero de 1994 hasta junio de 2002 en el Servicio de Cirugía General de Hospital General Universitario de Elche, Alicante. Se realizó resección del parénquima pulmonar mediante endograpadora lineal. La pleurodesis se llevó a cabo mediante pleurectomía apical o abrasión mecánica.
El tiempo operatorio disminuyó significativamente con la experiencia. Se resecaron bullas apicales (n = 75) o parénquima pulmonar apical sin identificar bullas (n = 25). En 2 casos fue necesaria la conversión a toracotomía. No se registró mortalidad perioperatoria. La estancia postoperatoria media fue de 5,7 días. Con la experiencia media actual de 4,25 años, solamente un caso requirió reintervención para abordar un fallo de tratamiento tras 30 días de la toracoscopia videoasistida: un caso de fuga aérea persistente de más de 7 días que fue tratada mediante una minitoracotomía lateral. Tras un seguimiento medio de 54 meses (rango, 6-107 meses) se registraron 4 recidivas (4%), que fueron tratadas con drenaje pleural (n = 3) o reposo (n = 1), sin que en ningún caso se precisara una reintervención. Todas las recurrencias aparecieron en el primer año de seguimiento postoperatorio.
La cirugía mediante toracoscopia videoasistida es un método seguro y efectivo de tratamiento del neumotórax espontáneo primario. Las tasas de recidiva a largo plazo son aceptables y similares a los resultados de la toracotomía abierta. El seguimiento a largo plazo no aumentó las tasas de recidiva.
To evaluate the immediate results of video- assisted thoracoscopic surgery for first-time and recurrent primary spontaneous pneumothorax and longterm outcomes.
We performed a retrospective study with long-term follow up. Eighty-eight consecutive patients who underwent thoracoscopy for 100 cases of primary spontaneous pneumothorax from January 1994 to June 2002 in the Elche General Hospital, in Alicante (Spain) were included. Lung parenchymal resections were made by means of endoscopic linear staple-cutters. Pleurodesis was achieved by apical pleurectomy or gauze abrasion.
Operating time decreased significantly with experience. Pleural apical bullae (n = 75) or a small portion of the apical upper lobe where no blebs were identified (n = 25) were resected. Two patients required conversion to thoracotomy. There was no perioperative mortality. The mean postoperative hospital stay was 5.7 days. At a current mean experience of 4.25 years, only one case has required reoperation due to treatment failure within 30 days of video-assisted thoracoscopic surgery (a persistent air leak treated by lateral limited thoracotomy). After a mean follow- up of 54 months (range 6-107 months), there were 4 recurrences (4%) treated with pleural drainage (n = 3) or rest (n = 1), none of which required reoperation. All the recurrences occurred within the first postoperative year.
Video-assisted thoracoscopic surgery is a safe and effective approach in the treatment of first-time and recurrent primary spontaneous pneumothorax. Long-term recurrence rates are acceptable and similar to results after open thoracotomy. Longterm follow-up did not increase the rate of recurrence.
Minimally invasive management for first and recurrent pneumothorax
1998, Annals of Thoracic Surgery
Minimally invasive techniques for treatment of pneumothorax should yield the standard of results set with open procedures: the operative morbidity should remain less than 15%, and the recurrence rate less than 1%. In the era before video-assisted thoracic surgery, two minimally invasive variants were used. Chemical pleurodesis resulted in an unsatisfactory recurrence rate of at least 15%. In contrast, pleurectomy and apical stapling performed through a transaxillary minithoracotomy compared favorably with larger thoracotomy approaches, and allowed a reduced hospital stay. Evaluation of video-assisted thoracic surgical operations for spontaneous pneumothorax is hampered by a lack of controlled studies. The general impression is that morbidity did not decline significantly; the main determinant of complications is the patient’s underlying health status. However, published recurrence rates range from 5% to 10%, in spite of a shorter follow-up time span. Optimized results are achieved when classic principles combining apical wedge resection and pleurodesis are applied. Reduction of hospital stay is not only a result of the new technology, but also changing drainage and discharge policies. Reduction of cost is debatable, because many studies do not consider the cost of video equipment. The main advantage when compared with open thoracotomy is reduction of postoperative pain. The only two available controlled studies conclude that there is no obvious advantage of video-assisted thoracic surgery when compared with conventional limited-access surgery. The future role of video-assisted thoracic surgery in this disease remains to be determined by a large-scale prospective evaluation.

View all citing articles on Scopus

View full text

Original articleLong-term results after tetracycline pleurodesis in spontaneous pneumothorax

Abstract

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Spontaneous pneumothorax in the USAF aircrew population: a retrospective study

Aviat Space Environ Med

Spontaneous pneumothorax. A review of 210 consecutive admissions to Royal Perth Hospital

Med J Austr

Original article
Long-term results after tetracycline pleurodesis in spontaneous pneumothorax