What are the recommendations for patients undergoing thoracoscopic bullectomy and pleurodesis?

From the Guidelines

For patients undergoing thoracoscopic bullectomy and pleurodesis, the primary recommendation is to follow the guidelines outlined in the most recent British Thoracic Society guideline for pleural disease, which emphasizes the importance of surgical pleurodesis to prevent recurrence of pneumothorax 1.

Key Recommendations

• Preoperative cessation of smoking at least 4-6 weeks before surgery
• Prophylactic antibiotics (typically a first-generation cephalosporin like cefazolin 1-2g IV) administered 30-60 minutes before incision
• Appropriate pain management with a multimodal approach including intercostal nerve blocks, patient-controlled analgesia, and oral analgesics

Postoperative Care

• Early mobilization within 24 hours to prevent complications
• Chest tubes should remain in place until air leaks resolve and drainage decreases to less than 150-200 mL per day
• Patients should avoid strenuous activities and heavy lifting for 4-6 weeks after surgery

Follow-up

• Follow-up chest X-rays are typically scheduled at 1-2 weeks, 1 month, and 3 months postoperatively
• Pulmonary rehabilitation may benefit patients with underlying lung disease, as suggested by previous guidelines 1

Surgical Approach

• Thoracoscopic bullectomy and pleurodesis are recommended for patients undergoing surgery for pneumothorax, with the goal of removing the suspected source of the air leak and preventing future episodes 1
• The use of talc pleurodesis is supported by previous studies, with a success rate of 91% 1
• However, the most recent guideline recommends surgical pleurodesis as the preferred method for preventing pneumothorax recurrence 1

From the FDA Drug Label

5 WARNINGS AND PRECAUTIONS 5.2 Interference with Future Procedures Sclerosis of the pleural space may preclude or complicate subsequent ipsilateral surgery and diagnostic procedures. Consider the possible effects of the use of Sterile Talc Powder on future diagnostic and therapeutic procedures prior to administration

The recommendations for patients undergoing thoracoscopic bullectomy and pleurodesis are to consider the potential effects of sclerosis of the pleural space on future diagnostic and therapeutic procedures prior to administration of Sterile Talc Powder 2.

• Key considerations:
  • Sclerosis of the pleural space may preclude or complicate subsequent ipsilateral surgery and diagnostic procedures.
  • Consider the possible effects of the use of Sterile Talc Powder on future diagnostic and therapeutic procedures prior to administration.

From the Research

Recommendations for Patients Undergoing Thoracoscopic Bullectomy and Pleurodesis

• The procedure is recommended for patients with complicated spontaneous pneumothorax, including those with bullae > 2 cm in diameter 3.
• Thoracoscopic bullectomy and pleurodesis can be performed safely and effectively in patients with primary spontaneous pneumothorax, with a low recurrence rate 4, 5.
• The addition of pleurodesis to video-assisted thoracoscopic bullectomy can prevent postoperative recurrences of pneumothorax without worsening postoperative chest pain or pulmonary function 4.
• The procedure can be performed in pediatric patients with spontaneous pneumothorax who fail initial management, with a low complication rate and no recurrence 5.
• Video-assisted thoracoscopic apical bullectomy and talc poudrage is an effective treatment for spontaneous pneumothoraces, with a low complication rate and recurrence rate, and only minor changes in pulmonary function at 1 year 6.
• Bullectomy using video-assisted thoracoscopic surgery (VATS) can be performed safely and effectively in patients with bullous emphysema, with symptomatic relief or improved pulmonary function postoperatively 7.

Preoperative and Postoperative Care

• Patients should undergo pulmonary function tests before and after surgery to assess lung function 6.
• Postoperative care should include pain control, such as paracetamol, and monitoring for complications, such as air leak or wound infection 5, 7.
• Patients should be followed up for at least 1 year to assess the effectiveness of the procedure and monitor for recurrence 4, 6.

Surgical Technique

• The procedure can be performed using video-assisted thoracoscopic surgery (VATS) with a low complication rate and no conversion to open surgery 4, 6.
• Pleurodesis can be achieved by electrocauterizing the upper surface of the parietal pleura in a patchy fashion or by using talc poudrage 4, 6.
• Bullectomy can be performed using VATS, with or without additional pleurodesis or suturing reinforcement 5, 7.