Video-Assisted Thoracoscopic Surgery for Primary Spontaneous Pneumothorax

Abstract

INTRODUCTION: Video-Assisted Thoracoscopic Surgery (VATS) is recommended for recurrent primary spontaneous pneumothorax and for first episode if associated with incomplete expansion of the lung, persistent air leak, hemopneumothorax or associated single large bullae. Empyema complicating after chest tube is a known complication .It depends on duration of the chest tube and underlying lung disease.We are reporting a case of empyema developing within 24 hours of chest tube , without apparent lung disease ,despite on antibiotics and requiring VATS for definitive therapy. CASE PRESENTATION: 42 year old African American woman with history of uterine fibroid and anemia presented to Emergency Department for sudden onset shortness of breath (SOB) and right sided chest pain after a straining maneuver. On Chest radiography(CXR) found to have a right pneumothorax and Wayne pig tail chest tube was placed. Follow up CXR showed small pneumoperitoneum, Computerized Tomography (CT) of abdomen revealed possible small bowel obstruction and right inguinal hernia. She was started on IVantibiotics. Patient refused laparoscopy and surgery. After 24 hours, pneumothorax resolved except for mild effusion. Patient was symptomatically better,hence the chest tube was removed .Pleural effusions were worsening in next few days ,however she signed against medical advice and following day (day 6)came to our hospital with worsening SOB, chest pain and fever. On exam, she was febrile and decreased breath sounds on entire right chest and reduced vocal fremitus CXR showed large pleural effusion with compression atelectasis which was confirmed by CT Chest(see image 1). Multiple attempts of thoracocentesis and tube thoracostomy failed to drain the effusion. Patient was started on IV antibiotics, evaluated by surgery and underwent VATS with decortication which removed more than a liter of serosanguinous loculated effusion with exuberant fibrosis. Pleural fluid LDH was high, blood and pleural fluid culture were negative. Pleural biopsy was negative for malignancy.Patient still refusing further work up for abdomen pathology.Patient was discharged home. Repeat CT Chest after 2 months revealed complete resolution of effusion (see image 2). DISCUSSION: There are several reasons which contribute to empyema in our patient such as iatrogenic infection during tube thoracotomy or secondary infection of small hemothorax or secondary infection from intraabdominal source with diaphragmatic disruptions.Careful management of effusions after pneumothorax is vital to prevent devastating complications. CONCLUSION(S): Primary spontaneous pneumothorax therapy is not always simple and complications do occur even after adequate sterile technique of chest tube insertion and despite receiving antibiotics.