Video-assisted thoracic surgery for primary spontaneous hemopneumothorax

Abstract

1 Introduction

Spontaneous hemopneumothorax (SHP) is a well-documented clinical condition that is associated with 1–12% of all spontaneous pneumothorax (SP) [1]. The patients can often deteriorate very quickly due to hemodynamic instability as a result of continued blood loss. Normal hemostasis by vasoconstriction and clot formation may be impeded by lung movement, changes in pleural pressure during respiration and absence of surrounding tamponade effect. Apart from fluid resuscitation and blood transfusion, surgical intervention is often required in the management of SHP. Tube thoracostomy, aspiration of hemothorax, thoracotomy, and decortication after the initial period of rest has all been used as treatment of SHP. Video-assisted thoracic surgery (VATS) has been used successfully in the management of SP with added advantages of less tissue trauma and less postoperative pain when compared with traditional thoracotomy approach [2,3]. More recently, VATS has been increasingly being used for the management of SHP with favorable results [4]. We report our experience in the management of SHP, and discuss the current knowledge on the treatment of this condition.

2 Materials and methods

A retrospective review of the departmental database between March 1988 and December 2002 revealed a total of 793 patients treated with SP in our institution. Among them, 30 (3.8%) patients presented with SHP. All the SHP patients had tube thoracostomy inserted as initial management, and subsequently, received surgery either at the time of admission or during the same hospital stay. Fluid resuscitation and blood transfusion was administered according to clinical signs, drain output and hematocrit levels. Standard posterolateral thoracotomies were performed early in our series for historical reasons when VATS was not established in our institute. We have been performing VATS since 1992, and from 1996 onwards all operations for SP or SHP used VATS approach. Our set up and technique of VATS have been previously described [5]. Their clinical data including sex, age, laterality of SHP, symptoms at presentation, signs of hypovolemia, admission hemoglobin (Hb) and hematocrit (Hct), amount of blood initially drained, total amount of blood transfused, the operative procedures and findings, duration of stay postoperatively, complication(s) of treatment and follow-up duration were recorded and analyzed.

Fisher's Exact test was used to detect association of categorical data such as SHP laterality and postoperative complications. Other clinical parameters such as postoperative hospital stay and follow-up duration were determined by Mann-Whitney U analysis. A two-sided P-value of less than 0.05 is considered significant.

3 Results

All the SHP patients were male with good past health, and 8 patients (26.7%) were regular smokers. There was no bilateral SHP and 13 patients (43.3%) presented with a left-sided SHP. Twenty-four patients (80%) developed SHP for the first time while 3 patients (10%) had previous contralateral SP and the other 3 patients (10%) had previous ipsilateral SP. The mean age of the patients was 25.1 years (range 17–49). All patients reported chest pain as an initial symptom and 24 patients (80%) experienced a sudden onset of breathlessness while 3 patients (10%) also reported coughing at admission. Signs of significant hypovolemia occurred in 4 patients (13.3%) at admission, with mean systolic blood pressure of 91 mmHg and mean pulse rate at 112 beats per minute, and mean admission Hb level of these 4 patients was 11.8 g/dl. They required fluid resuscitation and 3 of them received blood transfusion at admission.

Chest roentgenogram diagnosed SHP in 27 patients (90%) at presentation (Fig. 1) while the other 3 patients only demonstrated SP. Tube thoracostomy was inserted in all patients and the mean initial blood drained was 594 ml (range 0–2100 ml). For those who presented with signs of significant hypovolemia, the mean blood drained from the pleural cavity was 1380 ml (range 400–2100 ml) initially.

Fig. 1

Representative chest roentgenogram of spontaneous hemopneumothorax before surgical intervention.

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All SHP patients required surgery either at the time of admission or during the same hospital stay. Seven patients (23.3%) underwent emergency operations on the same day due to hemodynamic instability at presentation (n=4), high drain output (≫100 ml/h) and worsening clinical condition (drop in Hb and hemodynamic decompensation, etc.) in the first 24 h (n=3). Others had to undergo surgery during the hospital stay as a result of either SHP related complications (n=15) or because of their pneumothoraces (n=8) even when bleeding had subsided and Hb stabilized. (Table 1) The most delayed indications for surgery after SHP were clot empyema and persistent air leak.

Table 1

Delayed indication(s) for surgery due to spontaneous hemopneumothorax (SHP)

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Standard posterolateral thoracotomies were performed in 5 patients early in our series and the other 25 patients had VATS. There is no significant difference between age of open thoracotomy and VATS patients (P=0.63) (Table 2) . Patients in open and VATS groups were also comparable in laterality, hemodynamics at presentation, initial drainage, clot evacuated and follow-up. All patients except one had clots in the pleural cavity, and the mean clot volume evacuated was 872 ml (range 100–2000 ml). The source of bleeding was identified in 16 patients (53.3%); 12 of those patients (40%) a torn vascular adhesion band from apical parietal pleura was found to be the source of bleeding and in the remaining 4 patients, a vascular bleb was the bleeding source. Hemostasis for the torn vascular adhesions was achieved with electrocautery and endoscopic clips. Excision of bleb(s) or bulla(e), including vascular or bleeding bulla, was performed by endoscopic stapler device where appropriate. Mechanical pleurodesis with Marlex mesh mounted on endoscopic grasper was performed in all the patients.

Table 2

Patient characteristics of the 2 groups

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Postoperatively, 3 patients from thoracotomy group had postoperative complications (2 chest infections and 1 postoperative air leak, all treated conservatively) while only 2 of the 25 VATS patients (P=0.022) experienced postoperative complications (1 chest infection and 1 postoperative air leak, also treated conservatively) (Table 2). Upon tube thoracostomy removal, adequate pain control and satisfactory wound healing, patients were considered for discharge. Mean postoperative hospital stay was significantly shorter in the VATS compared with open thoracotomy group (P=0.0021). There is no significant difference in the mean follow up duration between VATS and open group (P=0.55). None of the patients had recurrence of SP or SHP during the follow up period. However, 1 patient in the open group and 1 patient from the VATS group developed contralateral pneumothoraces that were treated with VATS pleurodesis. In addition, two patients from VATS group developed contralateral SHP and required VATS surgery. (Table 2)

4 Discussion

SHP is an uncommon but potentially life-threatening clinical situation due to rapid ventilatory collapse and the large volume of concealed blood loss into the pleural cavity. In our series, it is one of the causes for patients presenting with unexplained signs of significant hypovolemia. SHP has also been reported to be associated with other conditions such as congenital cystic adenomatoid malformation, hemophilia, Ehlers-Danlos syndrome, sarcoidosis and systemic lupus erythematosis [6–10]. Chest roentgenogram remains the most useful investigation in the diagnosis of the condition. However, it should be emphasized that the admission chest roentgenogram in 10% of SHP patients showed only pneumothorax, with radiological evidence of hemothorax developing after tube thoracostomy. The initial impressions were hemothorax caused by thoracostomy tube insertion, but bleeding from vascular adhesions was later confirmed intra-operatively. Failure of the initial chest roentgenogram to show hemothorax can be due to the film being taken too early, supine rather than erect film or possibility of delayed hemorrhage from vascular adhesion band.

The source of the bleeding is either from a small non-contractile vessel in an area of torn vascular adhesion between the two layers of the pleurae, rupture of a vascular bulla or lung parenchyma at the apex of the lungs or the presence of an aberrant vessel that is usually thin-wall and does not contract adequately due to the lack of muscular fibres [11]. We were able to identify source of bleeding in 53% of SHP in our series, with the most common cause from a torn vascular adhesion band at apical parietal pleura accounting for three-quarters of SHP. In comparison, Wu et al. [4] were able to identify source of bleeding in 75% of their cases, and 50% were from an aberrant vessel. The reason for the relative infrequency of SHP in female is not clear but is well documented [4,12]. Fry et al. [12] suggested there is an increase bleeding tendency in male due to their additional strength and vigor but this theory failed to explain why SHP occurs while the patients are at rest. Two patients had no initial drainage from tube thoracostomy. The first patient had delayed bleeding from the torn vascular adhesion as recorded by the delayed high drain output. In the other patient, position of the tube thoracostomy was relatively apical causing a slight delay in the ‘initial’ drainage of hemothorax.

In the past, a conservative approach with tube thoracostomy, as for uncomplicated pneumothorax, has be used in selected group of SHP patients where bleeding subsides in 24 h [13]. However, all our patients required surgical intervention during the hospital stay because of hemodynamic instability, complications related to the SHP or persistent air leak with pneumothorax. Furthermore, there is also a potential pitfall of delay decortications due to re-accumulation of fluid in the pleural cavity [1] as shown in one of our patients. Similarly, Tatebe et al. found that 3 out of 4 SHP patients who were treated conservatively, later required decortication surgery [1]. Early surgery in the form of VATS may help reduce the incidence of delayed surgical exploration and decortication. The young age group of SHP patients places them in the low anesthetic risk category, and the benefit of performing surgery while patients are stable and not when they are decompensating hemodynamically should not be underestimated. In particular, VATS offers the added advantages of better view of the pleural cavity, identifying and stopping the bleeding directly, evacuation of clotted blood from pleural cavity, sealing the area of air leak with endoscopic stapler and mechanical pleurodesis, as well as placement of the drainage tube under direct thoracoscopic vision all performed under minimal access trauma [2]. When compared with the conventional thoracotomy operation, VATS is known to have quicker access time, less access trauma, reduced postoperative pain, and faster recovery with shorter postoperative hospital stay. Thus, VATS is increasingly considered as the better alternative to the open approach [2]. Results from our retrospective study support the practice of VATS in SHP with potential advantages of shorter postoperative stay and less complications to the patient compared with open surgery. However, VATS is contraindicated in patients with hemodynamic instability unless patient has prompt and complete response to fluid replacement therapy.

In conclusion, SHP is potentially a life-threatening condition and should be consider as a cause for patients presenting with unexplained signs of significant hypovolemia, particularly in young male patients. Early surgery may help reduce the incidence of delayed surgical exploration and decortication. Furthermore, surgery for SHP in the form of VATS should be considered, which could potentially result in less postoperative complications and shorter postoperative hospital stay compared with open thoracotomy. Larger prospective trials are warranted to better define the algorithms and role of VATS in the management of SHP.

References