Additional mechanical pleurodesis after thoracoscopic wedge resection and covering procedure for primary spontaneous pneumothorax

Evaluation and Management of Primary Spontaneous Pneumothorax in Adolescents and Young Adults: A Systematic Review From the APSA Outcomes & Evidence-Based Practice Committee

INTRODUCTION

Controversy exists in the optimal management of adolescent and young adult primary spontaneous pneumothorax. The American Pediatric Surgical Association (APSA) Outcomes and Evidence-Based Practice Committee performed a systematic review of the literature to develop evidence-based recommendations.

METHODS

Ovid MEDLINE, Elsevier Embase, EBSCOhost CINAHL, Elsevier Scopus, and Wiley Cochrane Central Register of Controlled Trials databases were queried for literature related to spontaneous pneumothorax between January 1, 1990, and December 31, 2020, addressing (1) initial management, (2) advanced imaging, (3) timing of surgery, (4) operative technique, (5) management of contralateral side, and (6) management of recurrence. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were followed.

RESULTS

Seventy-nine manuscripts were included. Initial management of adolescent and young adult primary spontaneous pneumothorax should be guided by symptoms and can include observation, aspiration, or tube thoracostomy. There is no evidence of benefit for cross-sectional imaging. Patients with ongoing air leak may benefit from early operative intervention within 24-48 h. A video-assisted thoracoscopic surgery (VATS) approach with stapled blebectomy and pleural procedure should be considered. There is no evidence to support prophylactic management of the contralateral side. Recurrence after VATS can be treated with repeat VATS with intensification of pleural treatment.

CONCLUSIONS

The management of adolescent and young adult primary spontaneous pneumothorax is varied. Best practices exist to optimize some aspects of care. Further prospective studies are needed to better determine optimal timing of operative intervention, the most effective operation, and management of recurrence after observation, tube thoracostomy, or operative intervention.

LEVEL OF EVIDENCE

Level 4.

TYPE OF STUDY

Systematic Review of Level 1-4 studies.

Current opinion and comparison of surgical procedures for the treatment of primary spontaneous pneumothorax

INTRODUCTION

Although three-port video-assisted thoracoscopic surgery (VATS) is the standard radical treatment for primary spontaneous pneumothorax (PSP), several issues need to be addressed as the postoperative recurrence rate remains relatively high. Although bullectomy is effective in preventing the postoperative recurrence of PSP, recurrent pneumothorax often occurs, requiring additional methods such as pleural covering with absorbable mesh sheets, surgical chemical pleurodesis, pleural abrasion, or pleurectomy. In addition, minimally invasive approaches that exceed three-port VATS are required according to the social demand. These approaches, such as uniportal VATS, reduced port surgery, and needlescopic surgery, have cosmetic merits, lower postoperative pain, and similar surgical results as three-port VATS.

AREAS COVERED

We focused on conventional and novel treatments for PSP in this article.

EXPERT OPINION

Effective methods that prevent postoperative recurrence and minimally invasive approaches will become popular in the near future.

Efficacy of pleural coverage with polyglycolic acid sheet after bullectomy for postoperative recurrence of spontaneous pneumothorax in young patients: a multi-institutional cohort study

OBJECTIVE

Various surgical procedures have been performed to decrease the recurrence of primary spontaneous pneumothorax after video-assisted thoracic surgery. This study aimed to examine the efficiency of pleural coverage for the prevention of postoperative recurrence in relatively young patients.

METHODS

Between January 2008 and December 2012, a total of 357 cases of 345 patients (age 15-29 years) with primary spontaneous pneumothorax who underwent bullectomy at 13 institutions were enrolled in this multi-institutional retrospective cohort study. A concurrent bilateral operation was counted as two cases. Polyglycolic acid sheets were used in 238 cases, and oxidized regenerated cellulose sheets were used in 37 cases to cover the visceral pleura, with no pleural coverage in 82 cases. The average observation period was 4.2 ± 2.0 years.

RESULTS

Postoperative recurrence was observed in 50 cases (14.0%) after video-assisted thoracic surgery. Twenty-six cases (10.9%) in the polyglycolic acid group, eight (21.6%) in the oxidized regenerated cellulose group, and sixteen (19.5%) in the non-coverage group experienced postoperative recurrence. Kaplan-Meier analysis revealed that the rate of freedom from postoperative recurrence in the polyglycolic acid group was significantly higher than that in the non-coverage group. Multivariate analysis showed that age ≥ 20 years and coverage with polyglycolic acid sheets were associated with reduced risk factors for postoperative recurrence.

CONCLUSION

Pleural coverage with a polyglycolic acid sheet is suggested to be effective in preventing postoperative recurrence of pneumothorax compared with non-coverage in relatively young patients.

The Evolution of Surgical Management for Children and Young Adults With Spontaneous Pneumothorax

BACKGROUND

Few studies have analyzed pediatric spontaneous pneumothorax (SPTX) nationally. We sought to better define this patient population and explore the evolution of surgical management.

METHODS

Patients (10-20 y old) with an International Classification of Diseases, Ninth Revision diagnosis of SPTX were identified within the Kids' Inpatient Database for the years 2006, 2009, and 2012. Diagnoses and procedures were analyzed by International Classification of Diseases, Ninth Revision codes. National estimates were obtained using case weighting.

RESULTS

There were 11,792 pediatric SPTX hospitalizations, and patients were predominantly male (84.0%), non-Hispanic white (69.0%), with a mean age of 17.2 y (95% confidence interval, 17.2-17.3). Overall, 52.5% underwent tube thoracostomy as the primary intervention, and more than one-third had a major surgical procedure (34.9%). From 2006 to 2012, there was an increase in bleb excisions from 81.1% to 86.9% and an increase in mechanical pleurodesis from 64.2% to 69.0%. There was a significant change from a predominantly open thoracotomy approach in 2006 (76.1%) to a video-assisted thoracoscopic approach in 2012 (89.3%).

CONCLUSIONS

Pediatric admission for SPTX results in tube thoracostomy in more than half of the cases and surgery in approximately one-third of the cases. Surgical intervention has changed to a more minimally invasive approach during the last decade, and counseling to patients and their families should reflect these updated management strategies.

LEVEL OF EVIDENCE

III.

Results of repeated video-assisted thoracic surgery for recurrent pneumothorax after primary spontaneous pneumothorax

OBJECTIVES

This study aimed to identify the causes of recurrent pneumothorax and to evaluate the results of repeated video-assisted thoracic surgery (VATS) for recurrent pneumothorax after VATS wedge resection for primary spontaneous pneumothorax (PSP).

METHODS

A retrospective review was conducted on 188 patients with recurrent PSP, of a population of 1414 patients who underwent VATS wedge resection for PSP. Reoperations were performed when an air leak persisted longer than 3 days after closed thoracostomy, when a visible bulla of greater than 1 cm on high-resolution computed tomography (HRCT) was observed and when rerecurrence took place after other treatments. The HRCT findings before and after recurrence were compared to evaluate the type of the new bulla. Patients were divided into 2 groups according to the additional procedure performed during the first operation; in Group I, a coverage procedure was performed, and in Group II, mechanical pleurodesis was performed after VATS wedge resection.

RESULTS

During a median follow-up period of 27.7 months, 76 patients underwent repeated VATS for ipsilateral recurrent PSP after VATS. The indications for repeated VATS were the presence of a bulla on HRCT in 41 patients and a persistent air leak in 35 patients. Group I comprised 36 patients and Group II comprised 40 patients. The HRCT findings showed no bulla in 3 (4%) patients, were suspicious for a bulla in 11 (15%) patients, showed a bulla at the staple line in 26 (34%) patients and showed a new bulla in a location other than on the staple line in 36 (47%) patients. The frequency of new bullae was not different between the 2 groups, but Group I showed a lesser tendency for bullae to occur at the staple line than Group II. Dense fibrosis around the staple line was also found intraoperatively.

CONCLUSIONS

Repeated VATS was a feasible method to treat recurrent PSP after VATS for PSP.

New bullae formation in the staple line increases the risk of recurrent pneumothorax following video-assisted thoracoscopic surgery bullectomy for primary spontaneous pneumothorax

Background

The study aimed to investigate the association between the recurrence of pneumothorax following video-assisted thoracoscopic surgery (VATS) for primary spontaneous pneumothorax (PSP) and the formation of new bullae.

Methods

This retrospective review examined patients who underwent VATS for PSP between April 2009 and December 2014. Of the 415 operated lungs, high-resolution computed tomography (HRCT) scans of 85 were analyzed.

Results

Of the 85 HRCT scans examined, 21 (24.7%) were diagnosed with recurrent pneumothorax and 60 new bullae were found. In total, 39 new bullae were located in the staple line, 38 were at other sites far from the staplers, and 17 were concurrent in the stapling and non-stapling areas. The group with new bullae in staple line exhibited significantly higher recurrence rate following VATS than the groups with no new bullae in the staple line (P=0.000, log-rank test). Cox regression analysis revealed that new bullae formation in the staple line [hazard ratio (HR), 26.664; P=0.003] and the volume of a resected pathology specimen (HR, 1.032; P=0.020) were independent risk factors for pneumothorax recurrence.

Conclusions

New bullae formation in the staple line increases the risk of recurrent pneumothorax following VATS. Thus, the current concept of VATS bullectomy-resect with sufficient margin-warrants reconsideration.

Covering the staple line with polyglycolic acid sheet versus oxidized regenerated cellulose mesh after thoracoscopic bullectomy for primary spontaneous pneumothorax

OBJECTIVE

The aim of this study was to compare coverage with oxidized regenerated cellulose mesh and that with polyglycolic acid sheet to decrease the incidence of postoperative recurrent pneumothorax.

METHODS

From August 2010 to August 2014, a total of 112 patients with primary spontaneous pneumothorax undergoing thoracoscopic bullectomy were enrolled. We compared the clinicopathological characteristics between recurrent and non-recurrent cases and examined their association with the material used for visceral pleural coverage: polyglycolic acid sheet versus oxidized regenerated cellulose mesh.

RESULTS

57 patients underwent thoracoscopic bullectomy plus coverage using oxidized regenerated cellulose mesh and 55 underwent thoracoscopic bullectomy plus coverage using polyglycolic acid sheet. The recurrence rate among all patients was 13.3%. No severe postoperative complications were observed in either group. There were no significant differences in the perioperative outcomes. However, the postoperative recurrence rate was significantly higher in the oxidized regenerated cellulose mesh group than in the polyglycolic acid sheet group (22.8 vs 3.6%).

CONCLUSIONS

Our results suggest that coverage with oxidized regerated cellulose mesh was not superior to coverage with polyglycolic acid sheet for postoperative recurrent pneumothorax.

Abrasion Plus Local Fibrin Sealant Instillation Produces Pleurodesis Similar to Pleurectomy in Rabbits

BACKGROUND

Pleurodesis performed either by pleurectomy or pleural abrasion is recommended in the approach to primary spontaneous pneumothorax to avoid recurrence. However, the efficacy of parietal pleural abrasion in producing pleurodesis is questioned. This study aims to determine the efficacy of apical abrasion alone, abrasion plus fibrin sealant application, and pleurectomy in producing pleurodesis in rabbits.

METHODS

Rabbits were subjected to video-assisted thoracic surgery alone (control) or to video-assisted thoracic surgery with apical gauze abrasion, abrasion plus fibrin sealant instillation, or apical pleurectomy. Blood samples were collected preoperatively and 48 h and 28 days postoperatively to measure total leukocytes (white blood cell count), neutrophil counts, and serum interleukin (IL)-8 levels. After 28 days the animals were sacrificed for macroscopic evaluation of the degree of apical pleurodesis and microscopic evaluation of local pleural fibrosis and collagen deposition.

RESULTS

White blood cell and neutrophil counts were similar in all groups, whereas the serum IL-8 level peaked at 48 h in all groups and decreased after 28 days, except in the pleurectomy group. After 28 days the abrasion plus fibrin sealant and pleurectomy groups had significantly more pleural adhesions, pleural fibrosis, and collagen deposition than the abrasion alone group, mainly due to thick mature fibers.

CONCLUSIONS

Abrasion with local fibrin sealant instillation is as effective as pleurectomy in producing pleurodesis in rabbits. Apical pleurectomy elicits a more persistent elevation of serum IL-8 levels than apical abrasion alone or abrasion plus fibrin adhesive instillation.

Air leakage on the postoperative day: powerful factor of postoperative recurrence after thoracoscopic bullectomy

BACKGROUND

Primary spontaneous pneumothorax (PSP) is a relatively common disorder in young patients. Although various surgical techniques have been introduced, recurrence after video-assisted thoracoscopic surgery (VATS) remains high. The aim of study was to identify the risk factors for postoperative recurrence after thoracoscopic bullectomy in the spontaneous pneumothorax.

METHODS

From January 2011 through March 2013, two hundreds and thirty two patients underwent surgery because of pneumothorax. Patients with a secondary pneumothorax, as well as cases of single port surgery, an open procedure, additional pleural procedure (pleurectomy, pleural abrasion) or lack of medical records were excluded. The records of 147 patients with PSP undergoing 3-port video-assisted thoracoscopic bullectomy with staple line coverage using an absorbable polyglycolic acid (PGA) sheet were retrospectively reviewed.

RESULTS

The median age was 19 years (range, 11-34 years) with male predominance (87.8%). Median postoperative hospital stay was 3 days (range, 1-10 days) without mortality. Complications were developed in five patients. A total of 24 patients showed postoperative recurrence (16.3%). Younger age less than 17 years old and immediate postoperative air leakage were risk factors for postoperative recurrence after thoracoscopic bullectomy by multivariate analysis.

CONCLUSIONS

Immediate postoperative air leakage was the risk factor for postoperative recurrence. However, further study will be required for the correlation of air leakage with recurrence.

Covering the staple line with a polyglycolic acid sheet after bullectomy for primary spontaneous pneumothorax prevents postoperative recurrent pneumothorax

BACKGROUND

Postoperative recurrent pneumothorax (PORP) can arise after surgery for primary spontaneous pneumothorax (PSP) that is recurrent or involves prolonged air leakage. In this study, which included 265 patients (279 cases) with PSP who underwent surgery at our department, the percentage of patients that did not experience PORP was compared between a group that underwent bullectomy alone (group A) and a group in which the staple line and the surrounding visceral pleura were covered with a PGA sheet after bullectomy (group B) in order to study the utility of PGA sheets for preventing PORP.

METHODS

Among the patients with PSP who underwent surgery, the cases of 92 patients (98 cases) from Group A and 173 patients (181 cases) from Group B were reviewed retrospectively. The incidence rates of PORP in these two groups were statistically analyzed in addition to the associations between PORP and age, gender, the affected side, height, body weight, height/weight ratio, smoking habits, or the surgical procedure.

RESULTS

In total, 96.7% of the patients in group B did not suffer PORP, which was significantly higher than the equivalent figure for group A (83.7%, log-rank test: P=0.0003). Moreover, among the examined parameters, only covering the staple line with a PGA sheet was found to be an independent prognostic factor (Cox regression: P=0.0003; HR =0.212; 95% CI, 0.082-0.547).

CONCLUSIONS

It was revealed that when bullectomy is performed in patients with PSP, wide coverage of the staple line and the surrounding visceral pleura with a PGA sheet significantly reduces the risk of PORP.

Management of large primary spontaneous pneumothorax in children: radiological guidance, surgical intervention and proposed guideline

PURPOSE

Primary spontaneous pneumothorax (PSP) is managed in accordance with the adult British Thoracic Society (BTS) guidelines due to lack of paediatric evidence and consensus. We aim to highlight the differences and provide a best practice surgical management strategy for PSP based on experience of two major paediatric surgical centres.

METHODS

Retrospective review of PSP management and outcomes from two UK Tertiary Paediatric hospitals between 2004 and 2015.

RESULTS

Fifty children with 55 PSP (5 bilateral) were referred to our Thoracic Surgical Services after initial management: 53% of the needle aspirations failed. Nine children (20%) were associated with visible bullae on the initial chest X-ray. Forty-nine children were assessed with computed tomography scan (CT). Apical emphysematous-like changes (ELC) were identified in 37 children (75%). Ten children had also bullae in the asymptomatic contralateral lungs (20%). In two children (4%), CT demonstrated other lung lesions: a tumour of the left main bronchus in one child; a multi-cystic lesion of the right middle lobe in keeping with a congenital lung malformation in another child. Contralateral asymptomatic ELC were detected in 20% of the children: of those 40% developed pneumothorax within 6 months. Best surgical management was thoracoscopic staple bullectomy and pleurectomy with 11% risk of recurrence. Histology confirmed ELC in 100% of the apical lung wedge resections even in those apexes apparently normal at the time of thoracoscopy.

CONCLUSION

Our experience suggests that adult BTS guidelines are not applicable to children with large PSP. Needle aspiration is ineffective. We advocate early referral to a Paediatric Thoracic Service. We suggest early chest CT scan to identify ELC, for counselling regarding contralateral asymptomatic ELC and to rule out secondary pathological conditions causing pneumothorax. In rare instance if bulla is visible on presenting chest X-ray, thoracoscopy could be offered as primary option.

The effect of pleural abrasion on the treatment of primary spontaneous pneumothorax: a systematic review of randomized controlled trials

BACKGROUND

Pleural abrasion has been widely used to control the recurrence of primary spontaneous pneumothorax (PSP). However, controversy still exists regarding the advantages and disadvantages of pleural abrasion compared with other interventions in preventing the recurrence of PSP.

METHODS

The PubMed, Embase, and Cochrane Central Register of Controlled Trials databases were searched up to December 15, 2014 to identify randomized controlled trials (RCTs) that compared the effects of pleural abrasion with those of other interventions in the treatment of PSP. The study outcomes included the PSP recurrence rate and the occurrence rate of adverse effects.

RESULTS

Mechanical pleural abrasion and apical pleurectomy after thoracoscopic stapled bullectomy exhibited similarly persistent postoperative air leak occurrence rates (p = 0.978) and 1-year PSP recurrence rates (p = 0.821), whereas pleural abrasion led to reduced residual chest pain and discomfort (p = 0.001) and a smaller rate of hemothorax (p = 0.036) than did apical pleurectomy. However, the addition of minocycline pleurodesis to pleural abrasion did not reduce the pneumothorax recurrence rate compared with apical pleurectomy (3.8% for both procedures) but was associated with fewer complications. There was no statistical difference in the pneumothorax recurrence rate between mechanical pleural abrasion and chemical pleurodesis with minocycline on either an intention-to-treat basis (4 of 42 versus 0 of 42, p = 0.12; Fisher exact test) or after exclusions (2 of 40 versus 0 of 42, p = 0.24; Fisher exact test). Pleural abrasion plus minocycline pleurodesis also did not reduce the pneumothorax recurrence rate compared with pleural abrasion alone (p = 0.055). Moreover, pleural abrasion plus minocycline pleurodesis was associated with more intense acute chest pain. The postoperative overall recurrence rate in patients who underwent staple line coverage with absorbable cellulose mesh and fibrin glue was similar to that with mechanical abrasion after thoracoscopic bullectomy (13.8% vs. 14.2%, respectively; p = 0.555), but staple line coverage resulted in less postoperative residual pain than mechanical abrasion (0.4% vs.3.2%; p<0.0001). Pleural abrasion after thoracoscopic wedge resection did not decrease the recurrence of pneumothorax compared with wedge resection alone (p = 0.791), but the intraoperative bleeding and postoperative pleural drainage rates were higher when pleural abrasion was performed.

CONCLUSIONS

In addition to resulting in the same pneumothorax recurrence rate, thoracoscopic pleural abrasion with or without minocycline pleurodesis is safer than apical pleurectomy in the treatment of PSP. However, minocycline pleurodesis with or without pleural abrasion is not any more effective than pleural abrasion alone. Moreover, additional mechanical abrasion is not safer than additional staple line coverage with absorbable cellulose mesh and fibrin glue after thoracoscopic bullectomy because of increased postoperative pain. Additionally, pleural abrasion after thoracoscopic wedge resection should not be recommended for routine application due to the greater incidence of adverse effects than wedge resection alone. However, further large-scale, well-designed RCTs are needed to confirm the best procedure.

Bilateral bullectomy through uniportal video-assisted thoracoscopic surgery combined with contralateral access to the anterior mediastinum

OBJECTIVE:

Video-assisted thoracoscopic surgery (VATS) has been a surgical intervention of choice for the treatment of spontaneous pneumothorax (SP) with lung bulla. Our objective was to introduce a uniportal VATS approach for simultaneous bilateral bullectomy and to evaluate its therapeutic efficacy.

METHODS:

Between May of 2011 and January of 2012, five patients underwent bilateral bullectomy conducted using this approach. All of the patients presented with bilateral SP. Preoperative HRCT revealed that all of the patients had bilateral apical bullae. We reviewed the surgical indications, surgical procedures, and outcomes.

RESULTS:

All of the patients were successfully submitted to this approach for bilateral bullectomy, and there were no intraoperative complications. The median time to chest tube removal was 4.2 days, and the median length of the postoperative hospital stay was 5.2 days. The median postoperative follow-up period was 11.2 months. One patient experienced recurrence of left SP three weeks after the surgery and underwent pleural abrasion.

CONCLUSIONS:

Bilateral bullectomy through uniportal VATS combined with contralateral access to the anterior mediastinum is technically reliable and provides favorable surgical outcomes for patients with bilateral SP who develop bilateral apical bullae. However, among other requirements, this surgical procedure demands that surgeons be experienced in VATS and that the appropriate thoracoscopic instruments are available.

Efficacy of polyglycolic acid sheet after thoracoscopic bullectomy for spontaneous pneumothorax

BACKGROUND

Various procedures have been performed to decrease the incidence of recurrent postoperative pneumothorax after thoracoscopic bullectomy. The purpose of this study was to determine the efficacy of a polyglycolic acid (PGA) sheet and pleural abrasion for prevention of recurrent postoperative pneumothorax.

METHODS

From January 2009 to August 2011, 257 patients underwent thoracoscopic bullectomy for primary spontaneous pneumothorax. In group A, 128 patients underwent pleural abrasion. These patients were compared with 129 patients (group B) who underwent a procedure to cover stable lines with an absorbable PGA sheet in addition to pleural abrasion.

RESULTS

There was no difference in preoperative demographics, although the age of patients in group A was statistically higher than that of patients in group B (23.67 ± 6.54 versus 21.69 ± 5.65; p = 0.010). In group A, prolonged postoperative air leaks (≥ 3 days) occurred more frequently (7.8% versus 2.3%; p = 0.045). A Kaplan-Meier curve showed that recurrence-free rates were higher in group B (p = 0.047).

CONCLUSIONS

Coverage with PGA sheet and pleural abrasion after thoracoscopic bullectomy is effective for preventing prolonged postoperative air leaks and reducing postoperative recurrence rates.

Thoracoscopic simultaneous bilateral bullectomy through apicoposterior transmediastinal access for bilateral spontaneous pneumothorax: a challenging approach

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) through transmediastinal access (TMA) for contralateral thoracic cavity is an operative alternative for bilateral pulmonary lesions. Recently, we introduced a novel method of apicoposterior TMA to perform simultaneous VATS bilateral bullectomy (BB) for bilateral spontaneous pneumothorax (BPTX). We retrospectively analyzed ten patients on whom this procedure was performed and evaluated the effectiveness of this approach.

METHODS

From April 2006 to May 2010, ten patients underwent simultaneous BB through this approach. Mean postoperative follow-up was 33.2 months. All patients were young males (age range = 15-20 years) and eight patients had BPTX that developed simultaneously. Apical blebs or bullae were carefully identified using multidirectional high-resonance computed tomography (HRCT). VATS right bullectomy was done first. The left thorax was reached by going through the apicoposterior mediastinum between the esophagus and vertebral bodies, and then left procedure was performed through this access.

RESULTS

All ten patients successfully underwent VATS BB through TMA without intraoperative complications. One patient developed prolonged air leakage for 6 days on the right side. During the follow-up period, two patients developed left PTX recurrence; one was treated with a chest tube at 13 months, and another underwent a left VATS reoperation at 20 months postoperatively because of new bulla formation around the previous stapling line.

CONCLUSIONS

A VATS apicoposterior transmediastinal approach is relatively safe and technically reliable for highly selective BPTX patients who have localized blebs or bullae on the left apical lung. Pleural reinforcement procedures may also be required for the prevention of postoperative recurrence.

Preventing recurrence of spontaneous pneumothorax after thoracoscopic surgery: a review of recent results

Spontaneous pneumothorax (SP) is now commonly treated with thoracoscopic surgery, which is associated with less pain and a shorter hospital stay than thoracotomy; however, in its initial stages, thoracoscopic stapled bullectomy resulted in an unexpectedly high incidence of postoperative SP recurrence. Thus, new thoracoscopic procedures, designed to be performed in addition to stapled bullectomy, were developed, which resulted in a gradual decline in the postoperative recurrence rate. We review the recent literature on SP recurrence after thoracoscopic surgery with these other surgical procedures. Pleurectomy and pleural abrasion have been performed for a long time with low recurrence rates; however, they cause the lung to adhere to the parietal pleura, often resulting in complications such as postoperative bleeding. Other surgical procedures that may be recommended to minimize the risk of recurrence are reinforcement of the staple lines using fleece-coated glue or an absorbable sheet. These procedures are now considered to be the thoracoscopic treatment of choice for SP.