The Role of Video Thoracoscopy in the Diagnosis and Choice of Treatment Method for Spontaneous Pneumothorax

The dissertation is dedicated to the role of video thoracoscopy in the diagnosis and selection of treatment methods for spontaneous pneumothorax complicating bullous lung disease. The research was conducted on a clinical material of 270 patients and includes the development of a differentiated diagnostic algorithm, determination of indications for emergency, urgent, and planned thoracoscopic interventions, and optimal methods of surgical treatment, taking into account clinical forms of the disease and the degree of respiratory insufficiency. Based on the application of modern video thoracoscopic techniques and computer diagnostics, the most informative differential-diagnostic signs of primary and secondary spontaneous pneumothorax were identified, allowing verification of the clinical form before the stage of lung re-expansion and substantiating the choice of a rational treatment method.

The complication of bullous lung disease in the form of spontaneous pneumothorax has been steadily increasing in recent years (Muromsky Yu.A. et al., 1998; Hazerrig S., Landreneau R., 1996; Waller D. et al., 2004); however, the results of treatment of this complex pathology using existing methods cannot be considered satisfactory. Thus, the number of pneumothorax recurrences following pleural punctures amounts to 20–45%, and after closed drainage of the pleural cavity — 12–18% (Nikoladze G.D. et al., 1998; Chatot M. et al., 1999; Ikeda M. et al., 2000). Chemical pleurodesis techniques are somewhat more effective (Lukomsky G.I. et al., 1991; Abakumov M.M., Abrosimov V.A., 1993; Bouvot J. et al., 1982; Spiegel M. et al., 1983; Stephenson L., 1985); however, such treatment has a number of drawbacks: following chemical irritation of the pleura, complications such as pleural effusion, prolonged hyperthermia, and chest pain are frequently observed (Vasilyev V.N., Sharov Yu.K., 1989; Vishnevsky A.A. et al., 1993; Abakumov M.M., Abrosimov V.A., 1993; Mattila S. et al., 1983; Gobbel J. et al., 1983).

Many authors recommend a more active surgical approach to spontaneous pneumothorax (Varlamov V.V., Kochorov S.D., 1996; Muromsky Yu.A. et al., 1998; Makarov A.V. et al., 1999; Torigoshi Y., 1995), but other researchers note the high traumatism of open thoracic interventions and a large number of complications, which lead to unsatisfactory functional outcomes (Priyma A.A. et al., 1988; Eizinger V.K., 1991; Abakumov M.M., Abrosimov V.A., 1993; Waller D., et al., 1994).

The contingent of patients with bullous emphysema is steadily increasing. Some authors consider it even an impending calamity of the late twentieth century, associating this growth with smoking, air pollution, and an increase in the number of patients with chronic bronchitis.

In the pathogenesis of spontaneous pneumothorax, the leading factors are disturbances of external respiration, circulation in the small circle of blood circulation, and deterioration of rheological properties of the blood. Circulation is impaired in both the affected and the healthy lung. Hypertension in the small circle and hypervolemia increase the cardiac load and, ultimately, impair its function (Dolina O.A. et al., 1992; Kukosh V.I., Makarov S.I., 1993; Martsyuk I.K., 1994; Shapkin B.C., Makarov V.I., 1994; Schuster S. et al., 1993).

The severity of cardiorespiratory disorders is determined by the extent of pneumothorax, the rate of air entry into the pleural cavity, the presence or absence of a valve mechanism, and the degree of mediastinal shift (Laptev A.N., 1982; Martsyuk I.K., 1984; Hernander M., et al., 1982; Wecden D., Smith G.H., 1983).

Pneumothorax is accompanied by pronounced disturbances of external respiration and central hemodynamics, which, in turn, can lead to cardiorespiratory complications.

Lung collapse in most cases is accompanied by reactive exudation into the pleural cavity, which provides a basis for the development of infection (Shapkin B.C., Makarov V.I., 1984; Euheman N., 1982; Wecden D., 1982; Smith G.H., 1983; Aubert M., et al., 1983).

Severe clinical forms of pneumothorax are not uncommon, and in combination with insufficiently effective treatment they are the cause of high mortality ranging from 1.3% to 10.4% (Stasyuk G.A., 1986; Shapkin B.C., Makarov V.I., 1984; Zwitz Ye., 1985).

At present, clinicians are not satisfied with the results of treatment of spontaneous pneumothorax, which is associated with the absence of a scientifically grounded diagnostic algorithm and a comprehensive therapeutic plan.

Given the great significance outlined above, there is a need to develop a diagnostic algorithm, a rational and adequate treatment strategy comprising the most effective methods for eliminating pneumothorax and its complications, as well as preventing recurrence.

Goal and Objectives of the Research

The goal of the present study is to improve the outcomes of treatment of patients with spontaneous pneumothorax by developing a diagnostic algorithm and a comprehensive set of therapeutic measures using modern video thoracoscopic techniques.

To achieve this goal, the following tasks were set:

1. To develop a diagnostic algorithm and differential-diagnostic criteria for the etiology of spontaneous pneumothorax.

2. To determine indications for emergency thoracoscopy in order to establish the treatment strategy and choice of method for spontaneous pneumothorax.

3. To determine indications and contraindications for the use of emergency, urgent, and planned methods of treatment of spontaneous pneumothorax, taking into account the severity of respiratory insufficiency.

4. To determine optimal methods of surgical treatment for primary and secondary pneumothorax, including the use of video thoracoscopic techniques.

Scientific Novelty

The present work is the first study dedicated to the problem of treatment of spontaneous pneumothorax based on a differentiated approach, taking into account the type of disease and respiratory insufficiency, through the application of modern video thoracoscopic techniques and computer diagnostics.

On a large clinical material (270 patients), computer analysis identified the most informative differential-diagnostic signs of primary and secondary spontaneous pneumothorax, allowing verification of the clinical form of the disease even before the stage of lung re-expansion, which makes it possible to choose the most rational treatment method.

Indications for emergency, urgent, and planned thoracoscopic investigations have been determined. The features of the thoracoscopic picture of primary and secondary spontaneous pneumothorax have been studied in detail. Optimal methods of surgical treatment of spontaneous pneumothorax have been developed, including the use of video thoracoscopic techniques, taking into account the clinical form of the disease. A treatment-diagnostic algorithm of physician tactics at spontaneous pneumothorax at various stages of medical care has been compiled.

Practical Significance

The developed specific practical recommendations on the treatment tactics of spontaneous pneumothorax, taking into account the severity of respiratory insufficiency and clinical forms, will significantly improve the outcomes of treatment of spontaneous pneumothorax. The developed differential-diagnostic criteria for clinical forms of spontaneous pneumothorax will make it possible to timely determine the causes and choose the most effective treatment method. The proposed diagnostic algorithm and choice of surgical treatment, including the application of video thoracoscopic techniques according to the developed indications, can be used in the practical work of thoracic surgery departments in large regional, city, and district hospitals.

Implementation of the Research Results

The main provisions of the dissertation are used in the practical work of the thoracic surgery department of City Clinical Hospital No. 50, surgical departments, the Main Clinical Hospital of the Ministry of Internal Affairs of the Russian Federation, Clinical Hospital No. 81, and the Veterans' War Hospital No. 1, which serve as the clinical base of the Department of Surgical Diseases and Clinical Angiology of Moscow State University of Medicine and Dentistry (MSUMD), and in the training of senior-year students, interns, clinical residents, postgraduate students, and resident physicians in the course of emergency surgery.

Dissertation Defence

The defence of the dissertation was held on September 28, 2007, at a joint meeting of the departments of surgical diseases and clinical angiology, general surgery of the medical faculty, urology, otolaryngology, and clinical pharmacology of MSUMD.

Main Propositions Presented for Defence

1. The most frequent cause of spontaneous pneumothorax is bullous lung disease.

2. The treatment tactics for spontaneous pneumothorax — puncture, drainage, thoracoscopy, surgical treatment — depend on the degree of respiratory insufficiency and the course of the disease.

3. The determining factors in the choice of treatment method are data from video thoracoscopy, computed tomography, and fibrobronchoscopy.

4. Recurrence of spontaneous pneumothorax is an indication for surgical treatment: video thoracoscopic or open lung resection.

Publications on the Dissertation Topic

Seven scientific works have been published on the dissertation topic, two of them in a journal recommended by the VAK RF.

Volume and Structure of the Work

The work is presented on 116 pages of typed text. It consists of an introduction and four chapters, a conclusion, summaries, practical recommendations, and a list of references used. The work is illustrated with 8 tables and 34 figures.