PURPOSE: To identify pulmonary abnormalities and histological findings in patients requiring surgical intervention for recurrent or persistent primary spontaneous pneumothorax (PSP).
METHODS: From January 2000 to December 2005, 144 consecutive patients underwent Video-assisted thoracoscopic (VATS) wedge excision and apical pleurectomy for PSP. Histological observation was used for microscopic features. All specimens were reviewed by the same pulmonary pathologist and looked for ruptured blebs/bullae or site of air leakage. The specimens were infused with formalin and leak was detected if there was ruptured bleb/bullae or air leak in the resected specimen.
RESULTS: This series included 116 male and 28 female patients (age, 24.6±5.8 years; range, 16-40 years). All patients were successfully treated using VATS. Recurrent pneumothorax was the most frequent indication for surgery, occurring in 80 cases. The method of management was stapling of an identified bleb or apex of the upper lobe and apical pleurectomy. Ninety-four patients had subpleural bullae/blebs formation (65%) (Figure 1) and 50 had emphysema without bullae (35%). Irregular emphysema was the most common pattern of emphysema identified (n=34). Other types of emphysema identified included distal acinar emphysema (n=10) and mixed irregular and distal acinar (n=6). The actual site of air leakage could be located at the site of subpleural blebs or bullae in 35 patients and elsewhere at the lung surface in 15 patients. Inflammatory changes in the lung of the patients were observed. In 73 patients, lung specimens showed either lymphocytic infiltration (n=52) or mixed lymphocytic and plasma cell infiltration (n=21). The remaining lung apices showed no cellular infiltration. Parietal pleura specimens showed either pleural fibrosis alone (n=81) (Figure 2), pleural fibrosis with mesothelial thickening and hyperplasia (n=21), or normal pleura (n=42).
CONCLUSION: In all cases of PSP, pathomorphologic changes were observed. Even when no apical bullae/blebs are identified, pathology of the resected apex virtually identifies emphysema on such specimens. The actual site of air leakage was seen in 35%.
CLINICAL IMPLICATIONS: The recurrence prevention technique should focus on the treatment of pleura.
DISCLOSURE: Adel Ayed, None.