Endoscopic Fibrin Pleurodesis in Complicated Pneumothorax

Abstract

Twenty-four patients with complicated pneumothorax were subjected to thoracosco-pically directed fibrin pleurodesis treatment. Through a three-lumen catheter, which was inserted via the operating canal of the thoracoscope, the two sealant components (fibrinogen, dissolved in aprotinin, and thrombin in a calcium chloride solution) were instilled. Insufflation of N₂O (3,5 atm) through the third catheter lumen caused nebulization of the two sealant components at the distal tip of the catheter. As soon as the sealant components mix, a gelatinous fibrin polymer develops on the pleural surface, which leads to formation of a mechanically competent seal. Parenchymatous fistulae of the lung which already exist, or which result from lysis of adhesions or coagulation of blebs, thus could be closed quickly and controlled directly under thoracoscopy.

In all cases, the collapsed lung reexpanded quickly. To the present time, only one recurrence has been observed, and this followed postoperative displacement of the chest tube. This corresponds to a recurrence rate of 4.1%. Pulmonary function tests performed in 11 patients revealed no functional impairment. For the reasons discussed, this method is preferable to the current pleurodesis techniques.

A “complicated” pneumothorax is a recurrent pneumothorax or a pneumothorax persisting for more than 5 days despite drainage. The frequency of recurrence may be related to the nature of the primary treatment. Thus recurrence rates of 25%–50% are associated with conservative therapy (bedrest), whereas rates of 10%–30% are seen following closed drainage treatment [1–7]. Since the recurrence rate is directly proportional to the number of prior recurrences [5], thoracoscopy is indicated in the management of recurrent pneumothorax. This procedure helps to determine whether pleurodesis treatment or surgical intervention is necessary. In our opinion, surgery is required in the presence of ruptured parenchymal bullae. Therefore we have tried to develop a thoracoscopic technique which:

• 1. Permits controlled and rapid closure of preexistent bronchopleural fistulae or of fistulae that result from endoscopic coagulation of small blebs or adhesions, thus ensuring rapid reexpansion of the collapsed lung

• 2. Leads to a sustained pleurodesis with a low rate of pneumothorax recurrence

• 3. Avoids eventual pleural fibrosis with resultant pulmonary restriction

• 4. Shortens drainage and thus hospitalization for patients with a complicated pneumothorax.