Sub-axillary cosmetic incision VS single-incision thoracoscopic surgery for primary spontaneous pneumothorax

doi:10.21203/rs.3.rs-1351964/v2

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Sub-axillary cosmetic incision VS single-incision thoracoscopic surgery for primary spontaneous pneumothorax

https://doi.org/10.21203/rs.3.rs-1351964/v2

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published 11 Jul, 2023

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Background

Recently, single-incision thoracoscopic surgery (SITS) has gained attention as an optimal treatment for the primary spontaneous pneumothorax (PSP). However, most SITS techniques use in the fourth to sixth intercostal space between the anterior axillary and mid axillary lines. To find out more concealed incisions, this study performed PSP surgery with the sub-axillary cosmetic incision (SACI) technique.

Methods

A total of 128 patients with PSP underwent video-assisted thoracoscopic surgery (VATS) at our institution between January 2017 and January 2019. These patients were evaluated and divided into SACI (n = 21) and SITS group (n = 57). Propensity score matching (PSM) was performed based on the patient’s backgrounds, and the enrolled cohort was divided into 21 pairs. The incision satisfaction was analyzed at 2 weeks and 6 months post-surgery.

Results

Twenty-one pairs with baseline characteristics matched into the two groups had no significant differences in their backgrounds and surgical results. However, the operation time was longer in the SACI group than in the SITS group (p = 0.013). There were no post-operative complications found in both groups. The incision satisfaction score in the SACI group was lower than the SITS group at 2 weeks and 6 months, and the difference was statistically significant (respectively, p = 0.022 and p = 0.039). There were no recurrences of ipsilateral pneumothorax in both groups.

Conclusions

SACI is a safe and feasible surgical method for the treatment of PSP. In addition, incision concealment can be used based on the choice for patients with incision needs.

Pneumothorax

Single-incision thoracoscopic surgery

Sub-axillary cosmetic incision

Propensity score matching

Video-assisted thoracoscopic surgery

PSP is the commonest chest disease in adolescents¹. The standard surgical procedure for these patients includes VATS bullectomy. Compared with the traditional thoracotomy, conventional three-port VATS provides significant benefits in reduced pain and respiratory function recovery². Recently, Gonzalez et al. ³ have shown that SITS has a better cosmetic effect and less incision pain than conventional multiport procedures. However, most SITS are made in the skin at the fourth to sixth intercostal space between the anterior axillary and mid axillary lines ^4,5. Further, Hee et al. ⁶ showed 70.4% satisfaction of wound scarring. These studies direct the need for a more concealed incision that can improve the comfort of wound scarring in PSP patients. Therefore, this study aims to evaluate the safety as well as the effectiveness of the SACI technique compared to SITS for treating PSP patients.

Between January 2017 and January 2019, we retrospectively reviewed the surgical records of 128 consecutive patients who underwent VATS for PSP. Written and oral informed consent was received by all patients. The present study was approved by the ethics committee of Wenzhou Central hospital (L2017-02-140).

Inclusion Criteria: 1) patients with primary spontaneous pneumothorax; 2) patients whose location and extent of bullae was verified by the pre-operative high-resolution computed tomography scans of the chest; 3) patients aged between 15 and 40 years; 4) patients without insertion of a chest tube before surgery.

Exclusion Criteria: 1) patients with no history of lung diseases, such as pulmonary fibrosis, pulmonary tuberculosis, chronic obstructive pulmonary disease; 2) patients with no history of ipsilateral lung surgery; 3) patients with co-morbidity of hemopneumothorax; 4)patients unwilling to accept surgical treatment, patients did not agree to provide consent; 5༉patients with life-threatening tension pneumothorax where emergency thoracic closed drainage is needed; 6) patients with incomplete records.

We surveyed age, sex, height, weight, intra-operative adhesions, smoking history, side involved, operation time, blood loss during surgery, post-operative drainage, duration of post-operative hospital stay, post-operative complications and post-operative pain scores evaluated using visual analog scales (VAS) from 0 (no pain) to 10 (worst pain ever experienced). Pain scores were recorded at 24h, 48h, 72h and the first week after surgery. In addition, all patients were follow-up for at least 6 months using post-operative telephone interviews. Postoperative recurrence was defined as the ipsilateral recurrence of pneumothorax requiring intervention treatment during the follow-up period. The follow-up was conducted to evaluate the level of satisfaction with the surgical wound and recorded in 4 grades (excellent = 1∼2, good = 3∼4, fair = 5∼6, and poor = 7∼8) at 2 weeks and 6 months after surgery. The detailed guideline of the scoring scale is shown in Table 1.

Table 1

Scoring scale
Grades	Scores	Incision performance
Excellent	1	Good concealment of incision and scar hyperplasia is not obvious
Excellent	2	Good concealment of incision and mild scar hyperplasia
Good	3	General concealment and mild scar hyperplasia
Good	4	General concealment and moderate scar hyperplasia
Fair	5	General concealment and severe scar hyperplasia
Fair	6	Poor concealment and mild scar hyperplasia
Poor	7	Poor concealment and moderate scar hyperplasia
Poor	8	Poor concealment and severe scar hyperplasia

Surgical technique

Using a double-lumen endotracheal tube and one-lung ventilation, two groups of surgeries were performed on the patients under general anesthesia. First, the patients were placed in a lateral decubitus position. Our surgical principle for PSP was to perform lung wedge resection with the same types of endoscopic stapler. No residual lesions were identified intra-operatively. Further, a water inundation test was performed to check for air leakage. Finally, a 20F chest tube was inserted into the top of the pleural cavity and connected to a water-sealed bottle through the incision site. An intradermal suture was performed around the tube with 3-0 Vicryl, and the chest tube was fixed with a suture knot that was not tied under the skin. The thread was removed after the chest tube was removed, and the 3-0 Vicryl suture was tightened further.

SITS technique

A 2.5-cm long skin incision was made in the fourth or fifth intercostal space between the anterior axillary line and mid axillary line. The protective sheath was placed in the incision. The 5-mm, 30⁰ thoracoscopy was introduced through the incision, to keep the thoracoscopy close to the mid axillary line. The whole chest was explored with lung collapse, whether there were adhesions, the location and the size of the bulla of the lung. Finally, the bulla was removed with the same type of endoscopic stapler (Fig. 1).

SACI technique

A 2.5-cm long skin incision was made in the axillary fold, exposing the intercostal space with a hook (because the skin incision was not parallel to the intercostal space, it was about 90 degrees), selected at the third intercostal space. The protective sheath was placed in the incision, the 5-mm, 30⁰ thoracoscopy was introduced through the incision, to keep the thoracoscopy close to the mid axillary line. The whole chest was explored with lung collapse, whether there were adhesions, the location and the size of the bullae of the lung, and the bullae were removed with the same type (Johnson Echelon 45) of the endoscopic stapler (Fig. 1).

Statistical analysis

PSM was performed to reduce the biases in patient selection. The logistic regression was used to calculate the propensity score. The covariates of age, sex, weight, height, side involved, intraoperative adhesions, and smoking history included in the calculation, which might affect the comparison result of the two groups. Patients in both groups were matched 1-to-1 with a caliper distance of 0.2; no replacement was required by SACI group. After PSM, the matching produced 21 patients in each group after PSM.

Data were analyzed using the Statistical Product and Service Solutions (SPSS) software (version22.0, SPSS Inc., Chicago, IL, USA) program. Categorical variables were presented as percentages and compared by the chi-square test or Fisher's exact test. Shapiro Wilk was used for the normality test (when p>0.05, the data is close to normal distribution). Continuous variables with normal distribution were expressed as medians ±standard deviation and compared by student's t-test. The Mann-Whitney U test was used to compare means of continuous variables with non-normal distribution; continuous variables were summarized as median and interquartile range, with statistical significance set at p<0.05.

A total of 128 consecutive patients underwent VATS for the treatment of PSP. Among them, cases of spontaneous hemopneumothorax (n = 4), incomplete medical records (n = 7), lung disease (n = 8), older than 40 or younger than 15 (n = 11), history of ipsilateral lung surgery (n = 1), and insertion of chest tube before surgery (n = 19) were omitted from the study. Subsequently, 78 patients were finally included in our study, 21 treated with SACI and 57 with SITS. The baseline characteristics of the included 78 patients are shown in Table 1, The denoted study selection process is shown in Fig. 4. The mismatched analysis revealed significant differences in the age and height of the two groups (p = 0.025 and p = 0.038, respectively). Before propensity score matching, the median age of the SACI group was 24.9 ± 6.6 years, with a median height of 169.8 ± 5.3 cm, 17 patients were male (81%), 7 patients smoked (33.3%), 2 patients had pleural adhesion (9.5%). The median age of SITS group was 22. 1 ± 3.9 years and the median height was 172.6 ± 5.2 cm. Out of 57 patients, 36 patients were male (63.2%), 13 patients were smokers (22.8%), and 10 patients had pleural adhesions (17.5%). Finally, 21 pairs of patients were matched for this study. No significant differences were observed on any baselines after PSM. The baseline characteristics post PSM are presented in Table 2. Post PSM, the median age was 24.9 ± 6.6 and 24.0 ± 4.4 years in the SACI and SITS groups, respectively. The surgical and post-operative outcomes after PSM are shown in Table 3. Patients receiving SACI had significantly longer surgical time than SITS (p = 0.013). However, the hospital stays after surgery, post-operative complications, pain scores on post-operative days, blood loss during surgery, and the post-operative drainage was similar in both groups. The SACI group had lower patient satisfaction scores than the SITS group at 2 weeks (Fig. 2) and 6 months (Fig. 3) after surgery, the difference was statistically significant (respectively, p = 0.022 and p = 0.039). Of note, no cases of post-operative complications were observed in either group during the follow-up period.

Table 2

The baseline characteristics of patients
	Before propensity score matching			After propensity score matching
Characteristics	SACI group (n = 21)	SITS group (n = 57)	p-value	SACI group (n = 21)	SITS group (n = 21)	p-value
Age(years)	24.9 ± 6.6	22.1 ± 3.9	0.025^a	24.9 ± 6.6	24.0 ± 4.4	0.17
Sex			0.135			1.00
Male	17(81%)	36(63.2%)		17(81%)	17(81%)
Female	4(19%)	21(36.8%)		4(19%)	4(19%)
Weight(kg)	57.1 ± 5.0	57.5 ± 4.3	0.752	57.1 ± 5.0	56.8 ± 3.9	0.467
Height(cm)	169.8 ± 5.3	172.6 ± 5.2	0.038^a	169.8 ± 5.3	170.3 ± 5.2	0.449
Side involved			0.993			0.938
Right	13(61.9%)	36(63.2%)		13(61.9%)	14(66.7%)
Left	6(28.6%)	16(28.1%)		6(28.6%)	5(23.8%)
Bilateral	2(9.5%)	5(8.8%)		2(9.5%)	2(9.5%)
Smoking			0.345			0.739
Yes	7(33.3%)	13(22.8%)		7(33.3%)	6(28.6%)
No	14(66.7%)	44(77.2%)		14(66.7%)	15(71.4%)
Pleural adhesion			0.605			0.663
Ys	2(9.5%)	10(17.5%)		2(9.5%)	4(19%)
No	19(90.5%)	47(82.5%)		19(90.5%)	17(81%)
SACI = sub-axillary cosmetic incision; SITS = single-incision thoracoscopic surgery; ap < 0.05, the difference was statistically significant. values are medians ± standard deviation for continuous variables or cases (%) for categorical variables.

Table 3

Postoperative events after propensity score matching
Characteristics	SACI group (n = 21)	SITS group (n = 21)	P-value
Operation time (min)	71.1 ± 11.6	58 ± 11.4	0.013^a
Blood loss during surgery (ml)	29.5 ± 18.0	27.1 ± 7.2	0.571
Postoperative drainage (ml)	134.3 ± 40.6	134.8 ± 31.4	0.971
Postoperative hospital stays (d)	2.5 ± 0.7	2.4 ± 0.6	0.629
Postoperative complication			1.00
Yes	0	0
No	21 (100%)	21 (100%)
Pain scores after surgery
24h median (interquartile)	3(1–9)	4(1–10)	0.878
48h	2(1–5)	2(1–6)	0.432
72h	2(1–3)	2 (1–3)	0.776
The first. week	1(1–2)	1(1–2)	1.0
Wound satisfaction scores (2-weeks)	3(1–5)	4(2–6)	0.022^a
Wound satisfaction scores (6-months)	3(1–6)	4(2–9)	0.039 ^a
SACI = sub-axillary cosmetic incision; SITS = single-incision thoracoscopic surgery; ap < 0.05, the difference is statistically significant. values are medians ± standard deviation or median (interquartile) for continuous variables or cases (%) for categorical variables.

Compared with the conventional thoracotomy, VATS has many advantages⁷. The conventional three-port VATS bullectomy is the most popular method for PSP surgery. However, patients who underwent conventional three-port VATS usually complain of post-operative pain and paresthesia⁸. To address these post-operative complications, efforts have been made to reduce the length of incisions, as the SITS approach reportedly had better cosmetic effects and lower rates of post-operative pain and paresthesia⁹. Nonetheless, converting three holes to a single hole is a long process, requiring technological progress apart from appropriate instruments. For example, Racco G et al.¹⁰ introduced SITS for treating PSP in 2004, but the SITS technique was not widely used in the last decade. The instrument collision that needed a relatively long skin incision was one of the hindrances for its wide acceptance. Moreover, the lack of flexible instruments like double joints made it impossible for the operator to complete the operation in a single narrow operation space. To minimize collisions between surgical instruments and reduce incision size, Mogi et al.¹¹ described a SITS technique which utilized a thin puncture device similar to a retractor. Bong et al.¹² modified the SITS technique using a wound protector and a bidirectional anchoring suture, whereas Tsuboshima K et al. ¹³ used a chest wall pulley for PSP. Despite that, the above single hole operation techniques have not been widely adopted and popularized because of the cumbersome operation steps prolonged operation, and complications in making the pulmonary bullectomy. In 2014, Ng et al.¹⁴ developed novel, smaller, and more specialized procedure-specific instruments for SITS, which allowed the reduction of incision size. Since then, with the continuous advances in endoscopic technology and the use of relatively new instruments, single hole thoracoscopic bullectomy has become more and more simple. Moreover, due to the emergence of new instruments, surgeons are becoming willing to accept and adopt the single-hole thoracoscopic bullectomy. Even though the incision is smaller than before, the wound scarring was not concealed enough, which affected the patient's satisfaction after surgery. Of note, cosmetics requests were more frequent among the younger patients. Therefore, we used the SACI technique, which used a more concealed way of suturing and resulted in better satisfaction, especially for young patients. The satisfaction score of the SACI technique was lower than SITS approach, and the difference is statistically significant.

We presented 128 cases of VATS for PSP, the 5-mm, 30⁰ thoracoscopy was used in all the bullectomy. This provided enough visual field for surgery, which was especially suitable for the 2.5-cm incision. At present, 5mm thoracoscopy is the best choice to reduce the operation space without affecting the operation field of vision. There was no conversion reported to open thoracotomy in both groups. Neither group had post-operative complications, indicating that the operation technology was safe and feasible. Previous studies have reported the high recurrence probability of pneumothorax after bullectomy which can be reduced by using pleural abrasion during the operation¹⁵. However, Hatz et al.¹⁶ showed that pleural abrasion would increase the post-operative thoracic drainage, delay extubation, promote post-operative complications and secondary operation difficulty. In our study, none of the surgical patients received any treatment for pleural abrasion and had no recurrence of pneumothorax during follow-up. However, the routine use of pleural abrasion is not recommended, especially for young patients.

Between both groups, no significant difference was observed for the hospital stay after surgery, post-operative complications, pain scores on post-operative days, blood loss during surgery, and post-operative drainage. However, the operation time of the SACI group was significantly prolonged than the SITS group (p = 0.013). In addition to the longer time caused by chest adhesion, the main reason was the surgical path. Due to the high position of sub-axillary cosmetic incision, relatively limited field of vision, especially it takes more time to remove the bullae in the lower lobe with endoscopic stapler.

The satisfaction of incision in the SCAI group was higher than the SITS group. First, the incision in the SACI group was at the axillary dermatoglyphic. After the patient hands dropped naturally, the incision position could hardly be seen. Given the convenience of post-operative follow-up, we evaluated the incision at 2 weeks postoperatively; however, at this time, the incision was not old enough for scar hyperplasia. Therefore, the incision looked smooth, and the satisfaction score was high. However, the overall satisfaction with the incision of the patients at 6 months after the operation was lower than the 2 weeks post-operation. This might have resulted as some patients had obvious scar hyperplasia from the incision 6 months after the operation in the SACI group. The axillary hair of these patients did not cover the scar completely, resulting in a decrease in post-operative satisfaction. Since this study had a short-term follow-up of 6 months after the operation, it was unclear whether the patient’s satisfaction with the incision would change one or more years after the operation.

As the treatment methods of pneumothorax were not randomly assigned, the baseline characteristics of the two treatment groups were different. The use of PSM reduced the deviation characteristics caused by the unbalanced covariates. Our study had few limitations. Although we used PSM to reduce selection bias, the total number of patients was small, and the post-operative follow-up time was short.

In this study, we found that the SACI was a safe and effective technique for PSP treatment. This single-center retrospective study of SACI for the treatment of PSP might be a potential alternative way to manage patients with PSP in selected cases, especially for patients with high requirements of wound concealment.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. Further inquiries can be directed to the corresponding author.

Ethics Statement

The studies involving human participants were reviewed and approved by Wenzhou Central Hospital(L2017-02-140). The patients/participants provided their written informed consent to participate in this study.

Author Contributions

YL-Z collected and recorded the original data. RS-H analyzed the data and was a major contributor in writing the manuscript. All authors contributed to the article and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding

None.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

We are gratefully to the following surgeons: Chi-chao Wang, Wen-Shen Ye and Liang-Da Jin.

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No competing interests reported.

Download PDF

Journal Publication

published 11 Jul, 2023

Read the published version in Journal of Cardiothoracic Surgery →

Editorial decision: Major revision
11 Dec, 2022
Reviews received at journal
05 Sep, 2022
Reviewers agreed at journal
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Submission checks completed at journal
15 Aug, 2022
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15 Aug, 2022
First submitted to journal
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You are reading this latest preprint version

Sub-axillary cosmetic incision VS single-incision thoracoscopic surgery for primary spontaneous pneumothorax

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