Suzuki Emily, Kurihara Masatoshi, Tsuboshima Kenji, Watanabe Kenichi, Okamoto Shouichi, Seyama Kuniaki
Pneumothorax Research Center and Division of Thoracic Surgery, Nissan Tamagawa Hospital, Tokyo, Japan.
Study Group for Pneumothorax and Cystic Lung Diseases, Tokyo, Japan.
J Thorac Dis. 2021 Jan;13(1):113-124. doi: 10.21037/jtd-20-2286.
Total pleural covering (TPC) is an innovative surgical procedure in which the entire visceral pleura is wrapped with sheets of oxidized regenerated cellulose (ORC) mesh under video-assisted thoracoscopic surgery. We have previously reported that TPC could successfully prevent pneumothorax recurrence in patients with lymphangioleiomyomatosis (LAM). However, the actual efficacy and preventive effect of TPC on pneumothorax recurrence remains unclear as many LAM patients already had pleural adhesion prior to TPC that was induced by thoracic surgery and/or pleurodesis. The purpose of this study is to evaluate the effects of TPC on pneumothorax recurrence and pulmonary function in LAM patients with no history of thoracic surgeries or pleurodesis.
We retrospectively reviewed medical charts of 52 patients (60 hemithoraces) who underwent TPC at our center, from January 2003 to September 2019, as a first surgical intervention for pneumothorax.
Pneumothorax recurrence occurred in 12 patients [14 of 60 hemithoraces (23.3%)] during the observation period [27 months (14.7; 56.4) = median (lower; upper quartiles)]. The probability of recurrence-free hemithorax post TPC was 81.1% at 2.5 years and 64.1% at 5 years. TPC did not produce a significant decrease in either VC %predicted (pred) or FEV/FVC. The pre- post-TPC median (lower; upper quartiles) VC %pred was 85.7% (79.7; 98.0) 87.2% (72.3; 95.6), P=0.535 and the FEV/FVC was 84.6% (75.7; 89.6) 83.0% (71.8; 87.0), P=0.667. Mechanistic/mammalian target of rapamycin (mTOR) inhibitors (mTORI) were subsequently initiated in 19 patients (36.5%) because of the progression of LAM. The postoperative FEVpred was significantly lower in patients who required mTORI than in those who did not [68.1% (57.3; 82.9) 88.7% (84.6; 89.8), P=0.020]; the decline rate in FEVpred/year from pre to post TPC was significantly greater in LAM patients who required mTORI than in those who did not [-9.37% (-4.73; 12.9) -1.94% (1.52; -4.50), P=0.029]. Postoperative complications were found in 25 of 52 hemithoraces (48.1%).
TPC can prevent pneumothorax recurrence without causing ventilatory impairment or severe pleural symphysis in LAM patients. TPC is an effective treatment option for LAM-associated pneumothorax based on its efficacy and safety.
全胸膜覆盖术（TPC）是一种创新的外科手术，即在电视辅助胸腔镜手术下，用氧化再生纤维素（ORC）网片包裹整个脏层胸膜。我们之前报道过，TPC能够成功预防淋巴管平滑肌瘤病（LAM）患者气胸复发。然而，由于许多LAM患者在接受TPC之前已经因胸外科手术和/或胸膜固定术导致胸膜粘连，TPC对气胸复发的实际疗效和预防效果仍不明确。本研究的目的是评估TPC对无胸外科手术或胸膜固定术病史的LAM患者气胸复发和肺功能的影响。
我们回顾性分析了2003年1月至2019年9月期间在本中心接受TPC的52例患者（60个半侧胸腔）的病历，这些患者将TPC作为气胸的首次外科干预措施。
在观察期[27个月（中位数（下四分位数；上四分位数）为14.7；56.4）]内，12例患者[60个半侧胸腔中的14个（23.3%）]出现气胸复发。TPC后无气胸复发的半侧胸腔在2.5年时的概率为81.1%，在5年时为64.1%。TPC并未使预测肺活量（VC）%pred或第一秒用力呼气容积/用力肺活量（FEV/FVC）显著降低。TPC前后的中位数（下四分位数；上四分位数）VC %pred分别为85.7%（79.7；98.0）和87.2%（72.3；95.6），P = 0.535，FEV/FVC分别为84.6%（75.7；89.6）和83.0%（71.8；87.0），P = 0.667。随后，由于LAM进展，19例患者（36.5%）开始使用机制性/哺乳动物雷帕霉素靶蛋白（mTOR）抑制剂（mTORI）。需要mTORI的患者术后预测FEV显著低于不需要的患者[68.1%（57.3；82.9）对88.7%（84.6；89.8），P = 0.020]；需要mTORI的LAM患者从术前到术后TPC时预测FEV每年的下降率显著大于不需要的患者[-9.37%（-4.73；12.9）对-1.94%（1.52；-4.50），P = 0.029]。52个半侧胸腔中有25个（48.1%）出现术后并发症。
TPC可预防LAM患者气胸复发，且不会导致通气功能损害或严重胸膜粘连。基于其疗效和安全性，TPC是治疗LAM相关气胸的有效选择。
