Thoracoscopic surgery under local anesthesia for high-risk intractable secondary spontaneous pneumothorax

Objectives To evaluate the outcomes of thoracoscopic surgery for intractable secondary spontaneous pneumothorax (SSP) under local anesthesia in high-risk patients and report intraoperative findings useful for identifying air leakage points. Methods We analyzed outcomes of 14 consecutive thoracoscopic operations under local anesthesia for high-risk SSP from 2015 to 2019. Suspicious lesions were determined based on intraoperative direct or indirect detections. Direct detection involved identifying pleural fistulas or air bubbles. Indirect detection involved finding thin and transparent bullae without any other suspicious lesions. Identifications of culprit lesions were confirmed by arrest or significant decrease in air leakage after surgical repair. All surgical repairs were followed by immediate single pleurodesis for a definitive cure and prevention of recurrence. Success was defined as the removal of the thoracic tube by surgical repair combined with immediate postoperative single pleurodesis. Results The main underlying pulmonary diseases were emphysema (n = 7), carcinoma (n = 3), interstitial pneumonia (IP) (n = 3), and nontuberculous mycobacterial infection (n = 1). A leakage point was identified in 13 cases (six on direct and seven on indirect detections). Success was achieved in nine cases (four on direct and five on indirect detections). Adverse events included one case of acute exacerbation of IP and one case of carbon dioxide narcosis. Conclusion Thoracoscopic surgery under local anesthesia can be the worthwhile definitive modality, among few remaining treatments, for highly fragile patients with SSP. Detecting air leakage directly and the presence of thin and transparent bullae without any other suspicious lesions can be clues for identifying culprit lesions.