TRANS AND POST-OPERATIVE CORRECTION OF TENSION PNEUMOTHORAX IN LAPAROSCOPIC ESOPHAGOGASTRIC JUNCTION SURGERY WITH TRANSIENT PLEURAL PUNCTURE: REPORT OF 44 CASES
Manuel P. Aguirre*, Javier A. Kuri, Francisco I. Galeana, Juan J. Solorzano
Surgery, American British Cowdray Hospital, Mexico, Mexico, Mexico
Fundoplication as the treatment of choice for gastroesophageal reflux disease is nowadays one of the most performed surgical procedures in the world. This procedure is not exempt of complications specially in Redo surgery, being one of the most frequent the parietal pleural injury during the high mobilization of the esophagus with the consequent tension pneumothorax, that in multiple occasions can compromise the hemodynamic stability of the patient and force the surgical team to take action and fix this situation during surgery. The incidence of pneumothorax varies from 0 to 8% depending on the surgeon's expertise. In giant hiatus hernia the incidence of pneumothorax can reach 22% and in Redo surgery varies among series between 12 to 25%.
In a total of 366 esophago-gastric junction surgeries during 4 years, 44 (12%) patients developed tension pneumothorax which was adequately solved by simple pleural puncture without the need of chest tube or any other pleural device.
Tension pneumothorax secondary to pneumoperitoneum during laparoscopic surgery can be fixed by simple pleural puncture with an IV catheter 14 or 16 French placed in the 2nd intercostal space along the clavicular midline, that is removed when the chest x-ray shows complete lung expansion. The assistance of the anesthesiologist by positive airway pressure helps to resolve the pneumothorax. No further management need's to be done, a 24 hour chest x-ray may help to confirm no residual pneumothorax. Supplementary oxygen is administered to all our surgical patients at least during the first 24 hours regardless the presence of pneumothorax.
Out of the 44 patients, 28 underwent Nissen-type fundoplication (8 giant hiatal hernia >10 cm) and 16 underwent Redo surgery, with a mean surgical time of 72 (±18) minutes for patients with Nissen fundoplication and a mean surgical time of 108 (±27) minutes for those with Redo. In 34 (78%) of them, pneumothorax could be resolved at the end of the surgery since it did not condition hemodynamic instability. In the remaining 10 (22%), transoperative management was required since they had final expiratory CO2 below 20mmHg, high peak airway pressure, SPO2 <85% and HR >100x'. Only 1 patient required management with pleural drainage for 36 hours as 30% residual pneumothorax was documented on 24 hour chest X-ray despite correct pleural puncture.
Because the mechanism of pneumothorax is due solely to the lesion of the parietal pleura preserving the integrity of the visceral pleura, simple pleural puncture as it has been described offers a resolution rate higher than 97%, with a complication rate less than 3% in the hands of a trained surgeon.
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