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Walker S, Hallifax R, Ricciardi S, Fitzgerald D, Keijzers M, Lauk O, Petersen J, Bertolaccini L, Bodtger U, Clive A, Elia S, Froudarakis M, Janssen J, Lee YCG, Licht P, Massard G, Nagavci B, Neudecker J, Roessner E, Van Schil P, Waller D, Walles T, Cardillo G, Maskell N, Rahman N. Joint ERS/EACTS/ESTS clinical practice guidelines on adults with spontaneous pneumothorax. Eur J Cardiothorac Surg 2024; 65:ezae189. [PMID: 38804185 DOI: 10.1093/ejcts/ezae189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 02/09/2024] [Indexed: 05/29/2024] Open
Abstract
OBJECTIVES The optimal management for spontaneous pneumothorax (SP) remains contentious, with various proposed approaches. This joint clinical practice guideline from the ERS, EACTS and ESTS societies provides evidence-based recommendations for the management of SP. METHODS This multidisciplinary Task Force addressed 12 key clinical questions on the management of pneumothorax, using ERS methodology for guideline development. Systematic searches were performed in MEDLINE and Embase. Evidence was synthesised by conducting meta-analyses, if possible, or narratively. Certainty of evidence was rated with GRADE (Grading, Recommendation, Assessment, Development and Evaluation). The Evidence to Decision framework was used to decide on the direction and strength of the recommendations. RESULTS The panel makes a conditional recommendation for conservative care of minimally symptomatic patients with primary spontaneous pneumothorax (PSP) who are clinically stable. We make a strong recommendation for needle aspiration over chest tube drain for initial PSP treatment. We make a conditional recommendation for ambulatory management for initial PSP treatment. We make a conditional recommendation for early surgical intervention for the initial treatment of PSP in patients who prioritise recurrence prevention. The panel makes a conditional recommendation for autologous blood patch in secondary SP patients with persistent air leak (PAL). The panel could not make recommendations for other interventions, including bronchial valves, suction, pleurodesis in addition to surgical resection or type of surgical pleurodesis. CONCLUSIONS With this international guideline, the ERS, EACTS and ESTS societies provide clinical practice recommendations for SP management. We highlight evidence gaps for the management of PAL and recurrence prevention, with research recommendations made. SHAREABLE ABSTRACT This update of an ERS Task Force statement from 2015 provides a concise comprehensive update of the literature base. 24 evidence-based recommendations were made for management of pneumothorax, balancing clinical priorities and patient views.https://bit.ly/3TKGp9e.
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Affiliation(s)
- Steven Walker
- Academic Respiratory Unit, Southmead Hospital, Bristol, UK
- Junior Chair of the Task Force
| | - Robert Hallifax
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Sara Ricciardi
- Unit of Thoracic Surgery, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
- Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Deirdre Fitzgerald
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia
- Medical School and Centre for Respiratory Health, University of Western Australia, Perth, Australia
| | - Marlies Keijzers
- Department of Surgery, Maxima Medical Center, Veldhoven, Netherlands
| | - Olivia Lauk
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Jesper Petersen
- Respiratory Research Unit PLUZ, Department of Respiratory Medicine Zealand, University Hospital, Naestved, Denmark
| | - Luca Bertolaccini
- Division of Thoracic Surgery IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Uffe Bodtger
- Respiratory Research Unit PLUZ, Department of Respiratory Medicine Zealand, University Hospital, Naestved, Denmark
| | - Amelia Clive
- North Bristol Lung Centre, Southmead Hospital, Bristol, UK
| | - Stefano Elia
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
- Thoracic Surgical Oncology Programme, Tor Vergata University Hospital, Rome, Italy
| | - Marios Froudarakis
- Medical School, Democritus University of Thrace, Alexandroupolis, Greece
- Medical School, University Jean Monnet, Saint Etienne, France
| | - Julius Janssen
- Department of Pulmonology, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
| | - Y C Gary Lee
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia
- Medical School and Centre for Respiratory Health, University of Western Australia, Perth, Australia
| | - Peter Licht
- Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark
| | - Gilbert Massard
- Department of Thoracic Surgery, University of Luxembourg, Hôpitaux Robert Schuman, Luxembourg, Luxembourg
| | - Blin Nagavci
- Institute for Evidence in Medicine, University Medical Center Freiburg, Freiburg, Germany
| | - Jens Neudecker
- Competence Center for Thoracic Surgery, Charité - Universitätsmedizin, Berlin, Germany
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| | - Eric Roessner
- Department of Thoracic Surgery, Center for Thoracic Diseases, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Paul Van Schil
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium
| | - David Waller
- Thorax Centre, St Bartholomew's Hospital, London, UK
| | - Thorsten Walles
- Clinic for Cardiac and Thoracic Surgery, Magdeburg University Hospital, Magdeburg, Germany
| | - Giuseppe Cardillo
- Unit of Thoracic Surgery, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
- Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Unicamillus-International University of Health Sciences, Rome, Italy
- Senior Chairs of the Task Force
| | - Nick Maskell
- Academic Respiratory Unit, Southmead Hospital, Bristol, UK
- North Bristol Lung Centre, Southmead Hospital, Bristol, UK
- Senior Chairs of the Task Force
| | - Najib Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Oxford NIHR Biomedical Research Centre, Oxford, UK
- Chinese Academy of Medical Sciences Oxford Institute, Oxford, UK
- Senior Chairs of the Task Force
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Walker S, Hallifax R, Ricciardi S, Fitzgerald D, Keijzers M, Lauk O, Petersen J, Bertolaccini L, Bodtger U, Clive A, Elia S, Froudarakis M, Janssen J, Lee YCG, Licht P, Massard G, Nagavci B, Neudecker J, Roessner E, Van Schil P, Waller D, Walles T, Cardillo G, Maskell N, Rahman N. Joint ERS/EACTS/ESTS clinical practice guidelines on adults with spontaneous pneumothorax. Eur Respir J 2024; 63:2300797. [PMID: 38806203 DOI: 10.1183/13993003.00797-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 02/09/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND The optimal management for spontaneous pneumothorax (SP) remains contentious, with various proposed approaches. This joint clinical practice guideline from the ERS, EACTS and ESTS societies provides evidence-based recommendations for the management of SP. METHODS This multidisciplinary Task Force addressed 12 key clinical questions on the management of pneumothorax, using ERS methodology for guideline development. Systematic searches were performed in MEDLINE and Embase. Evidence was synthesised by conducting meta-analyses, if possible, or narratively. Certainty of evidence was rated with GRADE (Grading of Recommendations, Assessment, Development and Evaluations). The Evidence to Decision framework was used to decide on the direction and strength of the recommendations. RESULTS The panel makes a conditional recommendation for conservative care of minimally symptomatic patients with primary spontaneous pneumothorax (PSP) who are clinically stable. We make a strong recommendation for needle aspiration over chest tube drain for initial PSP treatment. We make a conditional recommendation for ambulatory management for initial PSP treatment. We make a conditional recommendation for early surgical intervention for the initial treatment of PSP in patients who prioritise recurrence prevention. The panel makes a conditional recommendation for autologous blood patch in secondary SP patients with persistent air leak (PAL). The panel could not make recommendations for other interventions, including bronchial valves, suction, pleurodesis in addition to surgical resection or type of surgical pleurodesis. CONCLUSIONS With this international guideline, the ERS, EACTS and ESTS societies provide clinical practice recommendations for SP management. We highlight evidence gaps for the management of PAL and recurrence prevention, with research recommendations made.
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Affiliation(s)
- Steven Walker
- Academic Respiratory Unit, Southmead Hospital, Bristol, UK
- Junior Chair of the Task Force
| | - Robert Hallifax
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Sara Ricciardi
- Unit of Thoracic Surgery, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
- Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Deirdre Fitzgerald
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia
- Medical School and Centre for Respiratory Health, University of Western Australia, Perth, Australia
| | - Marlies Keijzers
- Department of Surgery, Maxima Medical Center, Veldhoven, The Netherlands
| | - Olivia Lauk
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Jesper Petersen
- Respiratory Research Unit PLUZ, Department of Respiratory Medicine Zealand, University Hospital, Naestved, Denmark
| | - Luca Bertolaccini
- Division of Thoracic Surgery IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Uffe Bodtger
- Respiratory Research Unit PLUZ, Department of Respiratory Medicine Zealand, University Hospital, Naestved, Denmark
| | - Amelia Clive
- North Bristol Lung Centre, Southmead Hospital, Bristol, UK
| | - Stefano Elia
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
- Thoracic Surgical Oncology Programme, Tor Vergata University Hospital, Rome, Italy
| | - Marios Froudarakis
- Medical School, Democritus University of Thrace, Alexandroupolis, Greece
- Medical School, University Jean Monnet, Saint Etienne, France
| | - Julius Janssen
- Department of Pulmonology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Y C Gary Lee
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia
- Medical School and Centre for Respiratory Health, University of Western Australia, Perth, Australia
| | - Peter Licht
- Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark
| | - Gilbert Massard
- Department of Thoracic Surgery, University of Luxembourg, Hôpitaux Robert Schuman, Luxembourg, Luxembourg
| | - Blin Nagavci
- Institute for Evidence in Medicine, University Medical Center Freiburg, Freiburg, Germany
| | - Jens Neudecker
- Competence Center for Thoracic Surgery, Charité - Universitätsmedizin, Berlin, Germany
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| | - Eric Roessner
- Department of Thoracic Surgery, Center for Thoracic Diseases, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Paul Van Schil
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium
| | - David Waller
- Thorax Centre, St Bartholomew's Hospital, London, UK
| | - Thorsten Walles
- Clinic for Cardiac and Thoracic Surgery, Magdeburg University Hospital, Magdeburg, Germany
| | - Giuseppe Cardillo
- Unit of Thoracic Surgery, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
- Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Unicamillus - International University of Health Sciences, Rome, Italy
- Senior Chairs of the Task Force
| | - Nick Maskell
- Academic Respiratory Unit, Southmead Hospital, Bristol, UK
- North Bristol Lung Centre, Southmead Hospital, Bristol, UK
- Senior Chairs of the Task Force
| | - Najib Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Oxford NIHR Biomedical Research Centre, Oxford, UK
- Chinese Academy of Medical Sciences Oxford Institute, Oxford, UK
- Senior Chairs of the Task Force
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Furuta C, Yano M, Kitagawa Y, Katsuya R, Ozeki N, Fukui T. Prospective Observation Study for Primary Spontaneous Pneumothorax: Incidence of and Risk Factors for Postoperative Neogenesis of Bullae. Ann Thorac Cardiovasc Surg 2024; 30:23-00206. [PMID: 38599823 PMCID: PMC11082493 DOI: 10.5761/atcs.oa.23-00206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 03/16/2024] [Indexed: 04/12/2024] Open
Abstract
PURPOSE Details of the neogenesis of bullae (NOB), which causes recurrent primary spontaneous pneumothorax (PSP) following bullectomy, have not been reported and risk factors for NOB remain unclear. We aimed to clarify the details of NOB. METHODS We conducted a prospective study using three computed tomography (CT) examinations performed 6, 12, and 24 months after bullectomy to identify the incidence of and risk factors for NOB. We enrolled 50 patients who underwent bullectomy for PSP. RESULTS After excluding 11 patients who canceled the postoperative CT examination at 6 months after bullectomy, only 39 patients were analyzed. The incidence of NOB at 6, 12, and 24 months after bullectomy was 38.5%, 55.2%, and 71.2%, respectively. The rate of NOB in the operated lung was almost 2 times higher than that in the contralateral nonoperative lung. Male sex, multiple bullae on preoperative CT, long stapling line (≥7 cm), deep stapling depth (≥1.5 cm), and heavier resected sample (≥5 g) were suggested to be risk factors for NOB. CONCLUSIONS We recognized a high incidence of postoperative NOB in PSP patients. Bullectomy itself seems to promote NOB. Postoperative NOB occurs frequently, especially in patients who require a large-volume lung resection with a long staple line.
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Affiliation(s)
- Chihiro Furuta
- Division of Chest Surgery, Department of Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Motoki Yano
- Division of Chest Surgery, Department of Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Yuka Kitagawa
- Division of Chest Surgery, Department of Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Ryotaro Katsuya
- Division of Chest Surgery, Department of Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Naoki Ozeki
- Division of Chest Surgery, Department of Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Takayuki Fukui
- Division of Chest Surgery, Department of Surgery, Aichi Medical University, Nagakute, Aichi, Japan
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Kang N, Zheng H, Ge W, Hu J, Liu W, Zhang R. Uniportal thoracoscopic bullectomy with improved parietal pleurectomy for primary spontaneous pneumothorax. THE CLINICAL RESPIRATORY JOURNAL 2023; 17:1341-1348. [PMID: 38043134 PMCID: PMC10730464 DOI: 10.1111/crj.13722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/25/2023] [Accepted: 11/08/2023] [Indexed: 12/05/2023]
Abstract
INTRODUCTION Parietal pleurectomy with bullectomy has been established as an effective method for preventing the recurrence of primary spontaneous pneumothorax (PSP). Our center introduced enhanced technical measures in uniportal thoracoscopic parietal pleurectomy with bullectomy for patients with PSP, aiming to document our initial experience and assess the procedure's effectiveness in preventing the recurrence of PSP. METHODS We analyzed the clinical data of 86 patients with PSP who underwent the improved uniportal thoracoscopic parietal pleurectomy with bullectomy between July 2019 and August 2022. During the procedure, the parietal pleura above the second intercostal space was stripped but not removed. Instead, it was retained in the thoracic cavity using a piece of pedunculated pleura. Subsequently, the stumps of the lung were covered by the preserved parietal pleura. RESULTS The results of the study showed that the mean operative time was 59.87 ± 16.93 min, and the postoperative drainage duration averaged 3.94 ± 2.17 days. The mean intraoperative blood loss was 24.33 ± 48.91 ml, and the mean postoperative drainage volume was 289.00 ± 170.03 ml. Prolonged air leakage for more than 5 days was observed in five patients (5.81%), but no other postoperative complications were recorded. During the follow-up, one patient (1.16%) experienced a recurrence of pneumothorax. CONCLUSIONS The perioperative results of bullectomy with the improved pleurectomy technique are deemed satisfactory. The various technical steps attempted at our center are found to be feasible and safe, and they may contribute to reducing the rates of recurrence in PSP.
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Affiliation(s)
- Ningning Kang
- Department of Thoracic SurgeryFirst Affiliated Hospital of Anhui Medical UniversityHefeiChina
| | - Hao Zheng
- Department of Thoracic SurgeryFirst Affiliated Hospital of Anhui Medical UniversityHefeiChina
| | - Wei Ge
- Department of Thoracic SurgeryFirst Affiliated Hospital of Anhui Medical UniversityHefeiChina
| | - Jin‐Xiu Hu
- Department of Thoracic SurgeryFirst Affiliated Hospital of Anhui Medical UniversityHefeiChina
| | - Wen Liu
- Department of Thoracic SurgeryFirst Affiliated Hospital of Anhui Medical UniversityHefeiChina
| | - Ren‐Quan Zhang
- Department of Thoracic SurgeryFirst Affiliated Hospital of Anhui Medical UniversityHefeiChina
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Spaans LN, van Steenwijk QCA, Seiranjan A, Janssen N, de Loos ER, Susa D, Eerenberg JP, Bouwman RA(A, Dijkgraaf MG, van den Broek FJC. Pain management after pneumothorax surgery: intercostal nerve block or thoracic epidural analgesia. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 37:ivad180. [PMID: 37941433 PMCID: PMC10645434 DOI: 10.1093/icvts/ivad180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 10/11/2023] [Accepted: 11/03/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVES In patients undergoing video-assisted thoracoscopic surgery for pneumothorax, the benefits and risks of single-shot intercostal nerve block as loco-regional analgesia are not well known. We retrospectively compared the effectiveness of intercostal nerve blocks as a viable alternative to thoracic epidural analgesia (TEA) regarding pain control and enhanced recovery. METHODS A retrospective multicentre analysis with single-centre propensity score matching was performed in patients undergoing video-assisted thoracoscopic surgery for pneumothorax receiving either TEA or intercostal nerve block. The primary outcome was a proportion of pain scores ≥4 (scale 0-10) until postoperative day (POD) 3. Secondary outcomes included variation in pain over time, additional opioid use, length of stay, mobility, complications and recurrence rate. RESULTS In 218 patients, TEA was compared to intercostal nerve block and showed no difference in the proportion of pain scores ≥4 {14.3% [interquartile range (IQR) 0.0-33.3] vs 11.1% (IQR 0.0-27.3) respectively, P = 0.24}, more frequently needed additional opioids on the day of surgery (18% vs 48%) and first POD (20% vs 42%), had a shorter length of stay (4.0 days [IQR 3.0-7.0] vs 3.0 days [IQR 2.8-4.0]) and were significantly more mobile until POD 3, while having similar recurrences. Intercostal nerve block had higher pain scores early in the course whereas TEA had higher late (rebound) pain scores. CONCLUSIONS In a multimodal analgesic setting with additional opioids, intercostal nerve block shows comparable moments of unacceptable pain from POD 0-3 compared to TEA and is linked to improved mobility. Results require randomized confirmation.
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Affiliation(s)
- Louisa N Spaans
- Department of Surgery, Maxima Medical Center, Eindhoven, Netherlands
- Department of Epidemiology and Data Science, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
- Methodology, Amsterdam Public Health, Amsterdam, Netherlands
| | | | - Adelina Seiranjan
- Department of Surgery, Maxima Medical Center, Eindhoven, Netherlands
| | - Nicky Janssen
- Department of Surgery, Zuyderland Medical Centre, Heerlen, Netherlands
| | - Erik R de Loos
- Department of Surgery, Zuyderland Medical Centre, Heerlen, Netherlands
| | - Denis Susa
- Department of Surgery, Bravis Hospital, Bergen op Zoom, Netherlands
| | - Jan P Eerenberg
- Department of Surgery, Tergooi Medical Centre, Hilversum, Netherlands
| | - R A (Arthur) Bouwman
- Department of Anesthesiology and Pain Medicine, Catharina Hospital, Eindhoven, Netherlands
- Department of Electrical Engineering, Signal Processing Systems, Eindhoven Technical University, Eindhoven, Netherlands
| | - Marcel G Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
- Methodology, Amsterdam Public Health, Amsterdam, Netherlands
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Speck KE, Kulaylat AN, Baerg JE, Acker SN, Baird R, Beres AL, Chang H, Derderian SC, Englum B, Gonzalez KW, Kawaguchi A, Kelley-Quon L, Levene TL, Rentea RM, Rialon KL, Ricca R, Somme S, Wakeman D, Yousef Y, St Peter SD, Lucas DJ. Evaluation and Management of Primary Spontaneous Pneumothorax in Adolescents and Young Adults: A Systematic Review From the APSA Outcomes & Evidence-Based Practice Committee. J Pediatr Surg 2023; 58:1873-1885. [PMID: 37130765 DOI: 10.1016/j.jpedsurg.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/15/2023] [Accepted: 03/31/2023] [Indexed: 05/04/2023]
Abstract
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.
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Affiliation(s)
- K Elizabeth Speck
- Mott Children's Hospital, University of Michigan, Division of Pediatric Surgery, Ann Arbor, MI, USA.
| | - Afif N Kulaylat
- Penn State Children's Hospital, Division of Pediatric Surgery, Hershey, PA, USA
| | - Joanne E Baerg
- Presbyterian Health Services, Division of Pediatric Surgery, Albuquerque, NM, USA
| | | | - Robert Baird
- British Columbia Children's Hospital, Vancouver, Canada
| | - Alana L Beres
- St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Henry Chang
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | | | - Brian Englum
- University of Maryland Children's Hospital, Baltimore, MD, USA
| | | | | | | | | | - Rebecca M Rentea
- Children's Mercy-Kansas City, Department of Surgery, Kansas City, MO, USA
| | | | - Robert Ricca
- University of South Carolina, Greenville, SC, USA
| | - Stig Somme
- Children's Hospital Colorado, Aurora, CO, USA
| | | | - Yasmine Yousef
- Montreal Children's Hospital, McGill University, Montreal, Canada
| | - Shawn D St Peter
- Children's Mercy-Kansas City, Department of Surgery, Kansas City, MO, USA
| | - Donald J Lucas
- Division of Pediatric Surgery, Naval Medical Center San Diego, CA, USA; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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7
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Barton EC, Maskell NA, Walker SP. Expert Review on Spontaneous Pneumothorax: Advances, Controversies, and New Directions. Semin Respir Crit Care Med 2023. [PMID: 37321247 DOI: 10.1055/s-0043-1769615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
For decades, there has been scanty evidence, most of which is of poor quality, to guide clinicians in the assessment and management of pneumothorax. A recent surge in pneumothorax research has begun to address controversies surrounding the topic and change the face of pneumothorax management. In this article, we review controversies concerning the etiology, pathogenesis, and classification of pneumothorax, and discuss recent advances in its management, including conservative and ambulatory management. We review the evidence base for the challenges of managing pneumothorax, including persistent air leak, and suggest new directions for future research that can help provide patient-centered, evidence-based management for this challenging cohort of patients.
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Affiliation(s)
- Eleanor C Barton
- Academic Respiratory Unit, North Bristol National Health Service Trust, Bristol, United Kingdom
| | - Nick A Maskell
- Academic Respiratory Unit, North Bristol National Health Service Trust, Bristol, United Kingdom
| | - Steven P Walker
- Academic Respiratory Unit, North Bristol National Health Service Trust, Bristol, United Kingdom
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8
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Kabuto T, Omasa M, Nagata S, Tokushige K, Adachi T, Nakanishi T, Motoyama H. The effect of polyglycolic acid sheet in preventing postoperative recurrent pneumothorax: a prospective cohort study. J Cardiothorac Surg 2023; 18:13. [PMID: 36627669 PMCID: PMC9830893 DOI: 10.1186/s13019-023-02111-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 01/02/2023] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Primary spontaneous pneumothorax occasionally relapses, even after bullectomy; therefore, coverage of the bullectomy staple line for pleural reinforcement is common in Japan. However, the appropriate covering materials have not yet been determined. METHODS This was a longitudinal prospective cohort study. Data were available for patients aged < 40 years with primary spontaneous pneumothorax who underwent their first thoracoscopic bullectomy between July 2015 and June 2021. We used oxidized regenerated cellulose (ORC) sheets from July 2015 to June 2018, and polyglycolic acid (PGA) sheets from July 2018 to June 2021. The postoperative recurrence-free survival rate was evaluated. The characteristics of the recurrent cases (radiographic, intraoperative, and pathological findings) were also evaluated. The extent of pleural adhesions was classified into the following three groups: none, medium, or extensive. RESULTS A total of 187 patients were included in the study. There were 92 and 95 participants in the ORC and PGA sheet groups, respectively. The postoperative recurrence-free survival rates were significantly higher in the PGA sheet group than in the ORC sheet group (ORC group vs. PGA group, 82.9% vs. 95.4%, p = 0.031). In recurrent cases, there was a significant difference in terms of pleural adhesion (0.0% [12 of 12, none] vs. 100.0% [four of four, extensive], p < 0.001). CONCLUSIONS Compared with ORC sheets, PGA sheets are an effective material for preventing early recurrence of primary spontaneous pneumothorax. Strong local pleural adhesions potentially contribute to decreasing recurrence.
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Affiliation(s)
- Takafumi Kabuto
- grid.416289.00000 0004 1772 3264Department of Thoracic Surgery, Kobe City Nishi-Kobe Medical Center, 5-7-1, Kojidai, Nishi-Ku, Kobe, Hyogo 651-2273 Japan
| | - Mitsugu Omasa
- grid.416289.00000 0004 1772 3264Department of Thoracic Surgery, Kobe City Nishi-Kobe Medical Center, 5-7-1, Kojidai, Nishi-Ku, Kobe, Hyogo 651-2273 Japan
| | - Shunichi Nagata
- grid.416389.10000 0004 0643 0917Department of Thoracic Surgery, Nagara Medical Center, 1300-7 Nagara, Gifu, 502-8558 Japan
| | - Kosuke Tokushige
- grid.416289.00000 0004 1772 3264Department of Respiratory Medicine, Kobe City Nishi-Kobe Medical Center, 5-7-1, Kojidai, Nishi-Ku, Kobe, Hyogo 651-2273 Japan
| | - Taishi Adachi
- grid.416289.00000 0004 1772 3264Department of Thoracic Surgery, Kobe City Nishi-Kobe Medical Center, 5-7-1, Kojidai, Nishi-Ku, Kobe, Hyogo 651-2273 Japan
| | - Takao Nakanishi
- grid.416289.00000 0004 1772 3264Department of Thoracic Surgery, Kobe City Nishi-Kobe Medical Center, 5-7-1, Kojidai, Nishi-Ku, Kobe, Hyogo 651-2273 Japan
| | - Hideki Motoyama
- grid.416289.00000 0004 1772 3264Department of Thoracic Surgery, Kobe City Nishi-Kobe Medical Center, 5-7-1, Kojidai, Nishi-Ku, Kobe, Hyogo 651-2273 Japan
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9
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Recuero Díaz JL, Milián Goicoechea H, Carmona Soto P, Gálvez Muñoz C, Bello Rodríguez I, Figueroa Almánzar S, Foschini Martínez G, Genovés Crespo M, Soro García J, García Fernández JL, Rodríguez Suárez P, Obeso Carrillo A. Manejo quirúrgico del neumotórax espontáneo primario. Encuesta nacional del Grupo Emergente de Cirugía Torácica de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR). OPEN RESPIRATORY ARCHIVES 2023. [PMID: 37497256 PMCID: PMC10369589 DOI: 10.1016/j.opresp.2022.100213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Introduction In February 2022, the Emerging Thoracic Surgery Group of the Spanish Society of Pneumology and Thoracic Surgery initiated a multicenter study on the surgical management of primary spontaneous pneumothorax (PSP). As a preliminary step, this survey was developed with the aim of finding out the current situation in our country to specify and direct this project. Method A descriptive study was carried out based on the results of this survey launched through the Google Docs® platform. The survey was sent to all active national thoracic surgeons, a total of 319. It consisted of 20 questions including demographic, surgical and follow-up data. Results We obtained 124 responses (39% of all specialists and doctors in training in the national territory). The most consistent indications were: homolateral recurrence for 124 (100%), lack of resolution of the episode for 120 (96.7%), risk professions for 104 (84%) and bilateral pneumothorax for 93 (75%). The approach of choice for 100% of respondents was videothoracoscopy. Of these, 96 contemplated pulmonary resection of obvious lesions (77%). Regarding the pleurodesis technique, pleural abrasion was the technique most used by 70 respondents (56.7%) while 49 (40%) performed chemical pleurodesis with talc either alone or in combination with mechanical pleurodesis. Conclusions While there is some consistency in some aspects of surgical management of PSP, this survey makes evident the variability in pleurodesis techniques applied among surgeons in our country.
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Benhaïm E, Roth B, Michel F, Merrot T, Dubus J. Management of primary spontaneous pneumothorax in teenagers: An 11-year study. Acta Paediatr 2022; 111:845-849. [PMID: 34923666 DOI: 10.1111/apa.16223] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/29/2021] [Accepted: 12/16/2021] [Indexed: 10/19/2022]
Abstract
AIM Management of teenagers with primary spontaneous pneumothorax (PSP) is not consensual. We report our experience over an 11-year period. METHODS For each patient under 20 years hospitalised with PSP from 2008 to 2018, demographic data, smoking habits, clinical presentation, hospitalisation unit, radiological management and its results, therapeutic management (observation, needle aspiration, chest tube drainage and surgery), complications, length of stay, given advice at discharge and recurrence were collected. RESULTS Seventy patients were included in different paediatric or adult surgery or pulmonology wards (82.9% boys; 16.8 ± 1.7 years; one severe presentation; 18/58 smokers). Chest CT-scan (n = 42/70, 60%) revealed blebs/bullae in 18/39 examinations (46.2%). Treatment consisted of observation (14/70, 20%), needle aspiration (2/70, 2.9%), chest tube (53/70, 75.7%) and video-assisted thoracoscopy surgery (27/70, 38.6%). Half patients with interventional procedure presented complications. A median of 10 chest X-rays was noted during a median stay of 8 days. Advice concerning sport practice, flying, smoking, etc., was variably delivered. PSP recurrence concerned 35/70 patients (50%) without identified predictive factors. CONCLUSION Compared to recent recommendations of a more conservative approach, chest CT-scan and interventional strategy are overused in our teenagers with PSP. Observation, more or less needle aspiration, should be clearly the first-line treatments.
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Affiliation(s)
- Eve Benhaïm
- Unité de Pneumologie Pédiatrique Centre Hospitalo‐Universitaire (CHU) Timone‐Enfants Marseille France
| | - Brimbelle Roth
- Département de Santé Publique Centre Hospitalo‐Universitaire (CHU) de la Conception Marseille France
| | - Fabrice Michel
- Unité d’Anesthésie‐Réanimation Pédiatrique Centre Hospitalo‐Universitaire (CHU) Timone‐Enfants Marseille France
| | - Thierry Merrot
- Département de Chirurgie Viscérale Pédiatrique Centre Hospitalo‐Universitaire (CHU) Timone‐Enfants Marseille France
| | - Jean‐Christophe Dubus
- Unité de Pneumologie Pédiatrique Centre Hospitalo‐Universitaire (CHU) Timone‐Enfants Marseille France
- Aix Marseille Université IRD AP‐HM MEPHI IHU‐Méditerranée Infection Marseille France
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Shigefuku S, Takahashi H, Ito M, Kajiwara N, Ohira T, Ikeda N. Significance of very-low-voltage coagulation plus coverage with polyglycolic acid sheet after bullectomy for primary spontaneous pneumothorax. Asian Cardiovasc Thorac Ann 2022; 30:2184923211072595. [PMID: 35040360 DOI: 10.1177/02184923211072595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The purpose of this study was to clarify the efficacy of the combination of low-voltage coagulation plus staple line coverage with a polyglycolic acid sheet after bullectomy for primary spontaneous pneumothorax to prevent a postoperative recurrence. METHODS A total of 143 patients who underwent bullectomy for primary spontaneous pneumothorax between January 2014 and December 2019 were enrolled in this study. We classified the patients into two groups based on additional procedures after bullectomy, namely, low-voltage coagulation for the margin of the staple line plus coverage with a polyglycolic acid sheet (Group A) and staple line coverage with a polyglycolic acid sheet alone (Group B). We evaluated perioperative factors and recurrence-free survival after surgery in the two groups. RESULTS Nine patients in Group B developed postoperative recurrences. In contrast, there was no postoperative recurrence in Group A. According to the Kaplan-Meier curves, the 2-year recurrence-free survival rates of the patients were 100% and 90.3%, in Group A and Group B, respectively. The log-rank test showed a significant difference between the two groups (p = 0.031). CONCLUSION Low-voltage coagulation for the margin of a staple line plus coverage with a polyglycolic acid sheet is a useful option as an additional technique after bullectomy for primary spontaneous pneumothorax to prevent a postoperative recurrence.
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Affiliation(s)
- Shunsuke Shigefuku
- Department of Surgery, 89440Hachioji Medical Center of Tokyo Medical University, Tokyo, Japan
| | - Hidenobu Takahashi
- Department of Surgery, 89440Hachioji Medical Center of Tokyo Medical University, Tokyo, Japan
| | - Maki Ito
- Department of Surgery, 89440Hachioji Medical Center of Tokyo Medical University, Tokyo, Japan
| | - Naohiro Kajiwara
- Department of Surgery, 89440Hachioji Medical Center of Tokyo Medical University, Tokyo, Japan
| | - Tatsuo Ohira
- Department of Surgery, Tokyo Medical University, Tokyo, Japan
| | - Norihiko Ikeda
- Department of Surgery, Tokyo Medical University, Tokyo, Japan
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12
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Woo W, Kim CH, Kim BJ, Song SH, Moon DH, Kang DY, Lee S. Early Postoperative Pneumothorax Might Not Be 'True' Recurrence. J Clin Med 2021; 10:jcm10235687. [PMID: 34884388 PMCID: PMC8658547 DOI: 10.3390/jcm10235687] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/27/2021] [Accepted: 11/30/2021] [Indexed: 11/16/2022] Open
Abstract
Objectives: To date, there is no consensual definition of what constitutes a postoperative recurrence of primary spontaneous pneumothorax (PSP), despite there being many studies reporting a high incidence of recurrence. This study aims to describe the long-term recurrence rates of pneumothorax and to suggest a possible way to differentiate recurrence events based on temporal patterns. Methods: This single-center study retrospectively evaluated all postoperative recurrence of PSP from January 2007 to May 2019. Patients’ demographics, history of pneumothorax, radiologic data, surgical technique, and the time between operation and recurrence were analyzed. Univariate and multivariable analyses were conducted to find potential risk factors related to long-term recurrence. Results: Of the 77 postoperative recurrent cases of pneumothorax, 21 (27.2%) occurred within 30 days after surgery and, thus, were classified as early recurrences (ER), while the remaining cases were classified as late recurrences (LR). There was no difference in preoperative variables between the two groups. However, the rate of incidence of second recurrence (SR), which represented a long-term prognosis, was significantly higher in the LR group (28.6% vs. 4.8%, p = 0.030). On univariate and multivariable analyses, late recurrence was the only significant factor predicting later recurrence events. Conclusion: Postoperative recurrence (PoR) within 30 days had a lower SR rate. Therefore, it might not be a ‘true’ postoperative recurrence with a favorable prognosis. Further studies investigating postoperative recurrence based on temporal patterns would be warranted to improve the classification of PoR.
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Affiliation(s)
- Wongi Woo
- Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea; (W.W.); (C.H.K.); (B.J.K.); (D.H.M.)
| | - Chong Hoon Kim
- Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea; (W.W.); (C.H.K.); (B.J.K.); (D.H.M.)
| | - Bong Jun Kim
- Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea; (W.W.); (C.H.K.); (B.J.K.); (D.H.M.)
| | - Seung Hwan Song
- Department of Thoracic and Cardiovascular Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul 01757, Korea;
| | - Duk Hwan Moon
- Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea; (W.W.); (C.H.K.); (B.J.K.); (D.H.M.)
| | - Du-Young Kang
- Department of Thoracic and Cardiovascular Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University College of Medicine, Seoul 03181, Korea
- Correspondence: (D.-Y.K.); (S.L.); Tel.: +82-02-2001-8543 (D.-Y.K.); +82-02-2019-3381 (S.L.); Fax: +82-02-2001-2049 (D.-Y.K.); +82-02-3461-8282 (S.L.)
| | - Sungsoo Lee
- Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea; (W.W.); (C.H.K.); (B.J.K.); (D.H.M.)
- Correspondence: (D.-Y.K.); (S.L.); Tel.: +82-02-2001-8543 (D.-Y.K.); +82-02-2019-3381 (S.L.); Fax: +82-02-2001-2049 (D.-Y.K.); +82-02-3461-8282 (S.L.)
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13
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Abstract
Pneumothorax is a common medical condition encountered in a wide variety of clinical presentations, ranging from asymptomatic to life threatening. When symptomatic, it is important to remove air from the pleural space and provide re-expansion of the lung. Additionally, patients who experience a spontaneous pneumothorax are at high risk for recurrence, so treatment goals also include recurrence prevention. Several recent studies have evaluated less invasive management strategies for pneumothorax, including conservative or outpatient management. Future studies may help to identify who is greatest at risk for recurrence and direct earlier definitive management strategies, including thoracoscopic surgery, to those patients.
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14
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Patterson KN, Lawrence AE, Beyene TJ, Aldrink JH, Michalsky M, Minneci PC. Recurrence Rates After Video-Assisted Thoracoscopic Surgery for Spontaneous Pneumothorax. J Laparoendosc Adv Surg Tech A 2021; 31:1424-1430. [PMID: 34748424 DOI: 10.1089/lap.2021.0335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Video-assisted thoracoscopic surgery (VATS) with pulmonary apical wedge resection is the mainstay procedure performed for spontaneous pneumothorax (sPTX). However, there is variability in adjunctive techniques, including pleurectomy or mechanical pleurodesis, used to prevent recurrences. The objectives of this study were to determine sPTX recurrence rates after initial VATS and to compare the efficacy of adjunct pleurectomy versus mechanical pleurodesis. Methods: Patients 11-21 years old who experienced sPTX and underwent initial VATS from December 2011 to December 2020 were identified at a single institution. Descriptive analyses and statistical tests were performed to identify factors associated with ipsilateral sPTX recurrence after surgery. Results: Fifty-six patients (48 males) underwent 58 VATS. The majority of patients were white (82.1%), male (85.7%), and nonsmokers (78.6%). Pleurectomy was performed in 27 (46.5%) cases, mechanical pleurodesis in 25 (43.1%), and pleurectomy with mechanical pleurodesis in 6 (10.3%). Overall, 15 patients (25.9%) experienced a postoperative recurrence, of which 8 (13.8%) required intervention. Recurrences occurred between 7 and 800 days after the index procedure. There was no significant difference in rates of overall recurrence between pleurectomy, mechanical pleurodesis, and pleurectomy with mechanical pleurodesis [7/27 (25.9%); 7/25 (28.0%); 1/6 (16.7%): P = .99] or recurrences requiring intervention between the three adjunctive techniques (5/27; 3/25; 0/6: P = .66). Conclusion: Over 25% of patients experience recurrence of sPTX after VATS. Recurrence rates were similar whether pleurectomy, mechanical pleurodesis, or pleurectomy with pleurodesis was performed. Further multi-institutional and prospective studies are needed to establish the optimal strategy to limit recurrence rates for pediatric patients with sPTX.
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Affiliation(s)
- Kelli N Patterson
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Amy E Lawrence
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Tariku J Beyene
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Jennifer H Aldrink
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Marc Michalsky
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Peter C Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
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15
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Young JS, Steimer DA, Polhemus E, Bueno R. Pleurabrade: A Spiral Brush for Mechanical Pleurodesis and a Review of the Literature. Thorac Cardiovasc Surg Rep 2021; 10:e36-e38. [PMID: 34667711 PMCID: PMC8519731 DOI: 10.1055/s-0041-1723950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 11/16/2020] [Indexed: 10/25/2022] Open
Abstract
Background While the optimal treatment for primary spontaneous pneumothorax remains unclear, mechanical pleurodesis is a well-established treatment. The Pleurabrade is a spiral brush designed for mechanical pleurodesis during thoracoscopy. We present two patients who underwent mechanical pleurodesis with the Pleurabrade. Case Description Two patients with spontaneous pneumothorax underwent operative intervention including mechanical pleurodesis with the Pleurabrade. Chest tubes were removed within 48 hours postoperatively and they were discharged home. Both patients remain recurrence free at 11 and 22 months, respectively. Conclusion While further testing is needed, these case reports and operative video highlight the Pleurabrade as an efficient device for thoracoscopic mechanical pleurodesis.
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Affiliation(s)
- John S Young
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Desiree A Steimer
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Emily Polhemus
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Raphael Bueno
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
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16
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Gilday C, Odunayo A, Hespel AM. Spontaneous Pneumothorax: Management and Prognosis. Top Companion Anim Med 2021; 45:100582. [PMID: 34509664 DOI: 10.1016/j.tcam.2021.100582] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/27/2021] [Accepted: 09/07/2021] [Indexed: 10/20/2022]
Abstract
This review article will review treatment and prognosis of spontaneous pneumothorax in dogs and cats. The advantages of surgical and medical management in dogs and cats, as well as current treatment practices, including autologous blood pleurodesis and small-bore chest tubes, will be discussed.
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Affiliation(s)
- Cassandra Gilday
- Department of Small Animal Clinical Sciences, University of Tennessee, Knoxville, TN, USA.
| | - Adesola Odunayo
- Department of Small Animal Clinical Sciences, University of Tennessee, Knoxville, TN, USA
| | - Adrien-Maxence Hespel
- Department of Small Animal Clinical Sciences, University of Tennessee, Knoxville, TN, USA
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Wilson PM, Rymeski B, Xu X, Hardie W. An evidence-based review of primary spontaneous pneumothorax in the adolescent population. J Am Coll Emerg Physicians Open 2021; 2:e12449. [PMID: 34179877 PMCID: PMC8212556 DOI: 10.1002/emp2.12449] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 02/03/2023] Open
Abstract
Primary spontaneous pneumothorax (PSP) is a relatively common problem in emergency medicine. The incidence of PSP peaks in adolescence and is most common in tall, thin males. Recent advances in the care of patients with PSP have called into question traditional approaches to management. This clinical review highlights the changing management strategies for PSP and concludes with a proposed evidence-based pathway to guide the care of adolescents with PSP.
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Affiliation(s)
- Paria M. Wilson
- Department of PediatricsUniversity of CincinnatiCollege of MedicineCincinnatiOhioUSA
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Beth Rymeski
- Division of Pediatric SurgeryCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Xuefeng Xu
- Department of RheumatologyImmunology & AllergyRespiratory MedicineThe Children's HospitalZhejiang University School of MedicineNational Clinical Research Center for Child HealthHangzhouChina
| | - William Hardie
- Department of PediatricsUniversity of CincinnatiCollege of MedicineCincinnatiOhioUSA
- Division of Pulmonary MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
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18
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Akras D, Raymond D, Akhrass R, Murthy S. Retention of Bovie scratch pad radio-opaque marker during VATS Pleurodesis: case report. J Cardiothorac Surg 2021; 16:126. [PMID: 33952292 PMCID: PMC8097857 DOI: 10.1186/s13019-021-01497-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/12/2021] [Indexed: 11/20/2022] Open
Abstract
Background Surgical intervention for spontaneous pneumothorax typically includes mechanical pleurodesis that frequently utilizes a Bovie scratch pad given its universal presence, low cost and ease of use. The pad is folded on itself after dividing it in half, allowing easier passage through the smaller incisions. However, unintentional foreign body retention may occur during the course of an operation leading to reoperations or even worse complications. This case is reported to raise awareness that dividing the scratch pad may allow the embedded radio-opaque marker to fall out and become retained as a foreign body. Case presentation The patient is a 41 year-old female who presented with shortness of breath secondary to spontaneous pneumothorax. Chest CT scan showed apical blebs. The patient underwent video assisted thorascopic surgery (VATS) with bleb resection and mechanical pleurodesis using a divided and folded bovie scratch pad. Postoperative chest x-ray showed a retained foreign body. Reoperation confirmed this to be the radio-opaque marker of the scratch pad and was removed. The patient did well and was discharged the following day. Conclusion Dividing the bovie scratch pad may damage and “weaken” the product allowing the radio- opaque marker to fall out during its use for pleurodesis and should be discouraged. Recommendation is made of using the scratch pad as a whole and not dividing it. Graphical abstract Retained radio-opaque marker of bovie scratch pad during VATS mechanical pleurodesis.
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Affiliation(s)
- Deena Akras
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Daniel Raymond
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Rami Akhrass
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Sudish Murthy
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
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19
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Brophy S, Brennan K, French D. Recurrence of primary spontaneous pneumothorax following bullectomy with pleurodesis or pleurectomy: A retrospective analysis. J Thorac Dis 2021; 13:1603-1611. [PMID: 33841952 PMCID: PMC8024846 DOI: 10.21037/jtd-20-3257] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Primary spontaneous pneumothorax is managed initially with observation and chest tube placement, followed by surgical intervention in select cases. With little currently published evidence, the role of surgical pleurodesis or pleurectomy to reduce primary spontaneous pneumothorax recurrence is unclear. This study compares the recurrence rates of primary spontaneous pneumothorax following bullectomy alone versus bullectomy with pleurodesis or pleurectomy. Methods A retrospective review was performed at a quaternary hospital for all patients undergoing surgery for primary spontaneous pneumothorax between June 2006 and December 2018. Patient demographics, disease severity, operative technique, and time between initial surgery and recurrence were recorded. Standard statistical techniques were used for univariable and multivariable analyses. Results Of 222 total included patients, 28 required a second surgery: 4 (1.8%) for prolonged air leak and 24 (10.8%) for recurrent pneumothorax. The median time from first to second surgery was 363 days and 35.7% of recurrences did not present until after two years. Age, sex, smoking, year of initial surgery, disease severity, and surgical technique did not significantly affect recurrence rate on univariable analysis. On multivariable analysis, the odds ratios of recurrence for bullectomy with mechanical pleurodesis or pleurectomy were respectively 0.82 and 0.15 (P=0.218), compared to bullectomy alone. Combined bullectomy, pleurectomy, and pleurodesis was most effective (0/18, 0%). Conclusions Bullectomy with pleurectomy and pleurodesis demonstrated a 0% recurrence rate for the treatment of primary spontaneous pneumothorax in this study. Statistical significance was not achieved in univariable or multivariable analyses comparing recurrence rates for the surgical approaches. A multi-center randomized controlled trial with longer follow-up than previously performed is needed to confirm these preliminary findings and optimize surgical management of primary spontaneous pneumothorax.
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Affiliation(s)
- Shawn Brophy
- Division of General Surgery, Department of Surgery, Dalhousie University, Queen Elizabeth II Hospital - Victoria Campus, Halifax, NS, Canada
| | - Kelly Brennan
- Dalhousie Medical School, Department of Surgery, Dalhousie University, Queen Elizabeth II Hospital - Victoria Campus, Halifax, NS, Canada
| | - Daniel French
- Division of Thoracic Surgery, Department of Surgery, Dalhousie University, Queen Elizabeth II Hospital - Victoria Campus, Halifax, NS, Canada
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Jeon HW, Kim YD, Sim SB. Should We Consider the Resected Lung Volume in Primary Spontaneous Pneumothorax? World J Surg 2021; 44:2797-2803. [PMID: 32328783 DOI: 10.1007/s00268-020-05522-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although bullectomy is the most curative treatment in primary spontaneous pneumothorax (PSP), postoperative recurrence is not uncommon. New bulla formation at the staple line is the most common cause of recurrence. However, the mechanism is not known. We believe that the pressure gradient plays the main role in new bulla formation. A large resection amount induces a prolonged pressure gradient for obliteration of the residual space. This study aimed to identify the association between resected lung volume and recurrence. METHODS The medical records of patients who underwent video-assisted thoracoscopic surgery (VATS) bullectomy were reviewed between October 2010 and December 2017. A total of 396 patients underwent surgery for spontaneous pneumothorax. The electronic medical records (EMRs) of the patients were reviewed. Patients with secondary spontaneous pneumothorax were excluded. Patients who were diagnosed with emphysema on CT were excluded. Patients with PSP were excluded from the study if the bulla was not located in the apex or if there was no ruptured bulla at the time of the operation. Patients who lacked EMRs were also excluded. We reviewed the medical records of 276 patients. The apical resected lung volume was estimated using a conical volumetric formula with the use of the specimen size. The risk factors for postoperative recurrence were analyzed. RESULTS The median age was 19 years old (range 13-36). A total of 261 patients were male (94.6%). The median body weight and body mass index (BMI) were 58 kg (range 40-82) and 18.92 (range 15.21-26.47), respectively. In 24 patients, both sides were operated on simultaneously. The resected lung volume was obtained by using a conical volumetric formula, and the value was divided by the BMI value. The median value was 1.43 (0.03-5.67). The median operative time was 35 min (range 15-120). The median postoperative day was 4 (range 2-12). Age (p = 0.006), the value of the resected lung volume divided by BMI (p = 0.003), bilateral bullectomy (p = 0.013) and transverse diameter (p = 0.034) were associated with postoperative recurrence according to the univariate analysis. According to the multivariate analysis, age and the value of the lung volume divided by BMI were significant risk factors for postoperative recurrence. CONCLUSIONS Younger age and a large resected lung volume and a low BMI are associated with postoperative recurrence after VATS bullectomy for PSP.
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Affiliation(s)
- Hyun Woo Jeon
- Department of Thoracic and Cardiovascular Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Bucheon, Seoul, 137-701, Republic of Korea
| | - Young-Du Kim
- Department of Thoracic and Cardiovascular Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Bucheon, Seoul, 137-701, Republic of Korea.
| | - Sung Bo Sim
- Department of Thoracic and Cardiovascular Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Bucheon, Seoul, 137-701, Republic of Korea
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Sim SKR, Nah SA, Loh AHP, Ong LY, Chen Y. Mechanical versus Chemical Pleurodesis after Bullectomy for Primary Spontaneous Pneumothorax: A Systemic Review and Meta-Analysis. Eur J Pediatr Surg 2020; 30:490-496. [PMID: 31600803 DOI: 10.1055/s-0039-1697959] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Primary spontaneous pneumothorax (PSP) and its high recurrence rate pose a therapeutic challenge to both patients and their managing surgeons. Mechanical or chemical pleurodesis can be used to prevent recurrence, but the optimal treatment often remains a matter of debate. This meta-analysis aims to compare the outcomes between mechanical and chemical pleurodesis following bullectomy for PSP. MATERIALS AND METHODS Studies published up to 2019 were searched from Medline, Embase, Google Scholar, and Cochrane databases. A meta-analysis of randomized controlled trials (RCTs) and observational cohort studies (OCSs) comparing outcomes between mechanical and chemical pleurodesis for PSP was performed. RESULTS Seven studies (one RCT and six OCSs) were included, comprising 1,032 cases of mechanical (799 abrasions, 202 pleurectomies, and 31 unspecified abrasions/pleurectomies/both), and 901 cases of chemical (643 talc, 69 minocycline, and 189 unspecified talc/kaolin) pleurodesis. The recurrence rate of pneumothorax after chemical pleurodesis (1.2%) was significantly lower than mechanical pleurodesis (4.0%) (pooled odds ratio [OR] = 3.00; 95% confidence interval [CI] = 1.59-5.67; p = 0.0007; I 2 = 19%). Hospital stay was also slightly shorter in the chemical pleurodesis group (pooled mean difference [MD] = 0.42 days; 95% CI = 0.12-0.72; p = 0.005; I 2 = 0%). There was no statistically significant difference in postoperative complications (pooled OR = 1.18; 95%CI = 0.40-3.48; p = 0.76; I 2 = 71%) and operative time (pooled MD = 3.50; 95%CI = -7.28 to 14.28; p = 0.52; I 2 = 99%) between these two groups. CONCLUSION Chemical pleurodesis is superior to mechanical pleurodesis following bullectomy for PSP in reducing hospital stay and recurrence rate. However, more RCTs with longer follow-up are necessary to demonstrate the benefit of chemical pleurodesis for PSP.
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Affiliation(s)
- Sarah Kher Ru Sim
- Department of General Surgery, Singapore General Hospital, Singapore
| | - Shireen Anne Nah
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Amos Hong Pheng Loh
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Lin Yin Ong
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Yong Chen
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
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Zhang C, Zhang M, Wang H, Ma Z, Wu Y, Fu L, Zhu T, Yu G. Next-day discharge following small uniportal thoracoscopic bullectomy assisted with an anchoring suture. J Int Med Res 2020; 48:300060519896926. [PMID: 31937154 PMCID: PMC7113697 DOI: 10.1177/0300060519896926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective Manipulating the instruments during uniportal video-assisted thoracoscopic surgery (U-VATS) bullectomy requires a relatively large incision. This study aimed to investigate the feasibility of next-day discharge following U-VATS bullectomy using an anchoring suture. Methods A stapler and a scope were inserted through a single incision in the anchoring group. The bullae were retracted by the suture, which was inserted from outside of the chest wall into the thorax, and then bullectomy was performed. For those in the control group, resection of the bullae was performed with the assistance of a grasping forceps. Results The length of the incision of the patients in the anchoring group ([13.2 ± 2.2] mm) was significantly smaller than in the control group ([26.2 ± 3.9] mm). In addition, the number of staplers used in the anchoring group was significantly less than in the control group ([1.2 ± 0.4] vs. [1.4 ± 0.5]). Furthermore, 36 (92.3%) cases in the anchoring group were uneventfully discharged within 24 hours after bullectomy. Conclusion Next-day discharge after U-VATS bullectomy through a small incision assisted with an anchoring suture is safe and feasible.
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Affiliation(s)
- Chu Zhang
- Department of Thoracic Surgery, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, Zhejiang, P.R. China
| | - Miao Zhang
- Department of Thoracic Surgery, Xuzhou Central Hospital Affiliated to Southeast University, Xuzhou, Jiangsu, P.R. China
| | - Haiyong Wang
- Department of Thoracic Surgery, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, Zhejiang, P.R. China
| | - Zhifeng Ma
- Department of Thoracic Surgery, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, Zhejiang, P.R. China
| | - Yuanlin Wu
- Department of Thoracic Surgery, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, Zhejiang, P.R. China
| | - Linhai Fu
- Department of Thoracic Surgery, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, Zhejiang, P.R. China
| | - Ting Zhu
- Department of Thoracic Surgery, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, Zhejiang, P.R. China
| | - Guangmao Yu
- Department of Thoracic Surgery, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, Zhejiang, P.R. China
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Recurrence of spontaneous pneumothorax six years after VATS pleurectomy: evidence for formation of neopleura. J Cardiothorac Surg 2020; 15:191. [PMID: 32723348 PMCID: PMC7389453 DOI: 10.1186/s13019-020-01233-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 07/20/2020] [Indexed: 12/03/2022] Open
Abstract
Background Primary Spontaneous Pneumothorax (PSP) is considered an absolute and definitive contraindication for scuba diving and professional flying, unless bilateral surgical pleurectomy is performed. Only then is there a sufficiently low risk of recurrence to allow a waiver for flying and/or diving. Case presentation A young fit male patient who suffered a PSP 6 years ago, and underwent an uncomplicated videoscopic surgical pleurectomy, presented with a complete collapse of the lung on the initial PSP side. Microscopic examination of biopsies showed a slightly inflamed tissue but otherwise normal mesothelial cells, compatible with newly formed pleura. Conclusions Even with pleurectomy, in this patient, residual mesothelial cells seem to have had the capacity to create a completely new pleura and pleural space. The most appropriate surgical technique for prevention of PSP may still be debated.
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Mendogni P, Vannucci J, Ghisalberti M, Anile M, Aramini B, Congedo MT, Nosotti M, Bertolaccini L, D’Ambrosio AE, De Vico A, Guerrera F, Imbriglio G, Pardolesi A, Schiavon M, Russo E. Epidemiology and management of primary spontaneous pneumothorax: a systematic review. Interact Cardiovasc Thorac Surg 2019; 30:337-345. [DOI: 10.1093/icvts/ivz290] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 11/06/2019] [Accepted: 11/10/2019] [Indexed: 02/02/2023] Open
Abstract
Abstract
Primary spontaneous pneumothorax (PSP) is one of the most common thoracic diseases affecting adolescents and young adults. Despite the high incidence of PSP and the availability of several international guidelines for its diagnosis and treatment, a significant behavioural heterogeneity can be found among those management recommendations. A working group of the Italian Society of Thoracic Surgery summarized the best evidence available on PSP management with the methodological tool of a systematic review assessing the quality of previously published guidelines with the Appraisal of Guidelines for Research and Evaluation (AGREE) II. Concerning PSP physiopathology, the literature seems to be equally divided between those who support the hypothesis of a direct correlation between changes in atmospheric pressure and temperature and the incidence of PSP, so it is not currently possible to confirm or reject this theory with reasonable certainty. Regarding the choice between conservative treatment and chest drainage in the first episode, there is no evidence on whether one option is superior to the other. Video-assisted thoracic surgery represents the most common and preferred surgical approach. A primary surgical approach to patients with their first PSP seems to guarantee a lower recurrence rate than that of a primary approach consisting of a chest drainage positioning; conversely, the percentage of futile surgical interventions that would entail this aggressive attitude must be carefully evaluated. Surgical pleurodesis is recommended and frequently performed to limit recurrences; talc poudrage offers efficient pleurodesis, but a considerable number of surgeons are concerned about administering this inert material to young patients.
Clinical trial registration number
International Prospective Register of Systematic Reviews (PROSPERO): CRD42018084247.
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Affiliation(s)
- Paolo Mendogni
- Thoracic Surgery and Lung Transplant Unit, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Jacopo Vannucci
- Department of Thoracic Surgery, Umberto I Hospital, University of Rome Sapienza, Rome, Italy
| | | | - Marco Anile
- Department of Thoracic Surgery, Umberto I Hospital, University of Rome Sapienza, Rome, Italy
| | - Beatrice Aramini
- Division of Thoracic Surgery, Department of Medical and Surgical Sciences for Children & Adults, University Hospital of Modena and Reggio Emilia, Modena, Italy
| | - Maria Teresa Congedo
- Division of Thoracic Surgery, Fondazione Policlinico Gemelli IRCCS, Catholic University of Sacred Heart, Rome, Italy
| | - Mario Nosotti
- Thoracic Surgery and Lung Transplant Unit, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Luca Bertolaccini
- Division of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Andrea De Vico
- Thoracic Surgery Unit, ASST Spedali Civili Brescia, Brescia, Italy
| | | | | | - Alessandro Pardolesi
- Unit of Thoracic Surgery, Foundation IRCCS National Cancer Institute of Milan, Milan, Italy
| | - Marco Schiavon
- Thoracic Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Emanuele Russo
- Division of Thoracic Surgery and Lung Transplantation, Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS ISMETT – UPMC, Palermo, Italy
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Video-Assisted Thoracic Surgery (VATS) Talc Pleurodesis Versus Pleurectomy for Primary Spontaneous Pneumothorax: A Large Single-Centre Study with No Conversion. World J Surg 2019; 43:2099-2105. [PMID: 30972431 DOI: 10.1007/s00268-019-05001-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Primary spontaneous pneumothorax (PSP) is a relatively common clinical entity with high incidence in the young population. Video-Assisted Thoracic Surgery (VATS) bullectomy and chemical or mechanical pleurodesis are two primary modalities of treatment. There has been much debate on the ideal mode of pleurodesis, but the literature on surgical outcomes comparing VATS pleurectomy with talc pleurodesis has been inconclusive. METHODS We performed a single-centre 5-year observational retrospective study of 202 patients who underwent VATS bullectomy with talc pleurodesis or parietal pleurectomy. RESULTS There were no significant differences in the demographics, pre-operative and intra-operative characteristics in both groups. Recurrence of pneumothorax, chest tube duration and hospital stay were similar in both groups. However, talc pleurodesis had a shorter operative time compared to pleurectomy. CONCLUSION Our study demonstrated comparable outcomes between talc pleurodesis and pleurectomy following VATS bullectomy for patients with PSP.
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Daemen JHT, Lozekoot PWJ, Maessen JG, Gronenschild MHM, Bootsma GP, Hulsewé KWE, Vissers YJL, de Loos ER. Chest tube drainage versus video-assisted thoracoscopic surgery for a first episode of primary spontaneous pneumothorax: a systematic review and meta-analysis. Eur J Cardiothorac Surg 2019; 56:819-829. [DOI: 10.1093/ejcts/ezz116] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 02/25/2019] [Accepted: 03/04/2019] [Indexed: 11/14/2022] Open
Abstract
Summary
Primary spontaneous pneumothorax affects up to 28 patients per 100 000 population yearly and is commonly resolved by chest tube drainage. However, drainage is also known to be associated with ipsilateral recurrence rates ranging from 25% to 43%. Preventive video-assisted thoracoscopic surgery (VATS) may be an effective alternative to diminish these recurrence rates and its associated morbidity. The aim of this study was to compare the efficacy of chest tube drainage and VATS as first line treatments of an initial episode of primary spontaneous pneumothorax. The MEDLINE, EMBASE, CENTRAL and Clinicaltrials.gov databases were searched through 16 September 2018. Data regarding the ipsilateral recurrence rate and the length of hospitalization were extracted and submitted to meta-analysis using the random-effects model and the I2 test for heterogeneity. Two randomized controlled trials and 2 observational studies were included, enrolling a total of 479 patients. Pairwise analysis demonstrated significantly reduced ipsilateral recurrence rates [odds ratio 0.15, 95% confidence interval (CI) 0.07–0.33; P < 0.00001] and length of hospitalization (standardized mean difference −2.19, 95% CI −4.34 to −0.04; P = 0.046) in favour of VATS. However, a significant level of heterogeneity was detected for the length of hospitalization (I2 = 97%; P < 0.00001). Subgroup analysis that stratified study design found no statistical differences regarding recurrence rate. In conclusion, VATS can be an effective and attractive alternative to standard chest tube drainage, with reduced ipsilateral recurrence rates and length of hospitalization. However, given the low quality of the majority of included studies, more well-designed randomized controlled trials are necessary to strengthen the current evidence.
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Affiliation(s)
- Jean H T Daemen
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Centre, Heerlen, Netherlands
| | - Pieter W J Lozekoot
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Centre, Heerlen, Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | | | - Gerben P Bootsma
- Department of Pulmonology, Zuyderland Medical Centre, Heerlen, Netherlands
| | - Karel W E Hulsewé
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Centre, Heerlen, Netherlands
| | - Yvonne J L Vissers
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Centre, Heerlen, Netherlands
| | - Erik R de Loos
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Centre, Heerlen, Netherlands
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27
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Aljehani YM, Almajid FM, Niaz RC, Elghoneimy YF. Management of Primary Spontaneous Pneumothorax: A Single-center Experience. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2019; 6:100-103. [PMID: 30787829 PMCID: PMC6196700 DOI: 10.4103/sjmms.sjmms_163_16] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: The prevalence of primary spontaneous pneumothorax is high in the Arab region. There is a lack of studies from the Eastern Province of Saudi Arabia highlighting the associated risk factors and demonstrating the effectiveness of surgical management. Objectives: To identify risk factors associated with primary spontaneous pneumothorax and to correlate the effectiveness of surgical management with the rate of disease recurrence. Subjects and Methods: This retrospective chart review included adult patients who presented with primary spontaneous pneumothorax and were managed at King Fahd Hospital of the University, Al-Khobar, Saudi Arabia, from January 1, 2005, to December 31, 2014. The results are presented as arithmetic mean for quantitative data, and chi-square test was used for statistical analysis. P ≤0.05 was considered statistically significant. Results: In total, 151 patients with primary spontaneous pneumothorax were included, with the majority being male (98.7%) and Saudis (88.7%). The mean age was 24 ± 6 years (range: 13–49 years), mean height 171 ± 8 cm (range: 144–193 cm) and mean body mass index 19.2 ± 3.8 kg/m2 (range: 13.3–39.0 kg/m2). About 62% of the patients were smokers. Ten patients had an ipsilateral recurrence of primary spontaneous pneumothorax after the first episode was successfully managed. Surgical exploration after the first episode itself was found to significantly reduce the recurrence rate. The study found that in the management of these patients, there was a shift from conventional open thoracotomy to the minimally invasive video-assisted thoracoscopic surgery method. Conclusions: The risk factors for primary spontaneous pneumothorax in this study were consistent with the current literature. Surgical exploration after the first episode of primary spontaneous pneumothorax significantly reduces the recurrence rate and there is a paradigm shift toward a less invasive surgical approach in managing these patients.
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Affiliation(s)
- Yasser Mahir Aljehani
- Division of Thoracic Surgery, Department of Surgery, College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Feras Mohammed Almajid
- Division of Thoracic Surgery, Department of Surgery, College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Rabia C Niaz
- Division of Thoracic Surgery, Department of Surgery, College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Yasser Farag Elghoneimy
- Division of Thoracic Surgery, Department of Surgery, College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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Onuki T, Kawamura T, Kawabata S, Yamaoka M, Inagaki M. Neo-generation of neogenetic bullae after surgery for spontaneous pneumothorax in young adults: a prospective study. J Cardiothorac Surg 2019; 14:20. [PMID: 30674336 PMCID: PMC6344986 DOI: 10.1186/s13019-019-0848-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 01/17/2019] [Indexed: 11/30/2022] Open
Abstract
Background To investigate the development of neogenetic bullae or blebs on 1-year postoperative chest computed tomography after video-assisted thoracic surgery (VATS) in young patients with primary spontaneous pneumothorax (PSP). Methods In this prospective study, 10- to 20-year-old patients with PSP were treated via VATS with additional procedures (bullectomy, cold coagulation, coverage, pleural abrasion, or chemical pleurodesis). All patients underwent the additional procedures and computed tomography of the chest 1 year postoperatively for the assessment of neogenetic bullae. Postoperative PSP recurrence was monitored, and recurrence-free survival was evaluated using Kaplan-Meier analysis. Results Fifty-seven patients (66 cases) aged 17 ± 2 years underwent VATS for PSP and were followed up for 938 ± 496 days. Of the 36 cases at 1-year follow-up, 23 (63.9%) showed neogenetic bullae, which were adjacent to the staple lines in 16 cases (69.6%). The 1- and 2-year recurrence-free survival rates were 88.9 and 85.1%, respectively. Nine of the 66 cases (13.6%) showed recurrence after 869 ± 542 days. A history of contralateral PSP was significantly associated with recurrence. Conclusions VATS, combined with additional procedures, provides acceptable long-term results in young patients with PSP. Additional procedures reduce the recurrence rate of PSP but do not prevent the occurrence of neogenetic bullae. A history of contralateral PSP is a potential risk factor for post-VATS recurrence in young patients.
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Affiliation(s)
- Takuya Onuki
- Department of General Thoracic Surgery, Tsuchiura Kyodo General Hospital, 4-1 Ohtsuno, Tsuchiura, Ibaraki, 300-0028, Japan.
| | - Tomoyuki Kawamura
- Department of General Thoracic Surgery, Tsuchiura Kyodo General Hospital, 4-1 Ohtsuno, Tsuchiura, Ibaraki, 300-0028, Japan
| | - Shuntaro Kawabata
- Department of General Thoracic Surgery, Tsuchiura Kyodo General Hospital, 4-1 Ohtsuno, Tsuchiura, Ibaraki, 300-0028, Japan
| | - Masatoshi Yamaoka
- Department of General Thoracic Surgery, Tsuchiura Kyodo General Hospital, 4-1 Ohtsuno, Tsuchiura, Ibaraki, 300-0028, Japan
| | - Masaharu Inagaki
- Department of General Thoracic Surgery, Tsuchiura Kyodo General Hospital, 4-1 Ohtsuno, Tsuchiura, Ibaraki, 300-0028, Japan
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Surgical Treatment of Spontaneous Pneumothorax: Pleural Abrasion or Pleurectomy? Surg Laparosc Endosc Percutan Tech 2018; 29:58-63. [PMID: 30499890 DOI: 10.1097/sle.0000000000000595] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE A primary spontaneous pneumothorax is a condition that occurs predominantly in young and thin male individuals who do not have any history of underlying lung disease. Various techniques such as pleural abrasion and pleurectomy are used to reduce the recurrence rate, but there exists no consensus among surgeons on which surgical technique offers the lowest risk of recurrence.We aimed to compare the efficiency and recurrence risk of pleural abrasion and pleurectomy methods in patients with primary spontaneous pneumothorax undergoing a wedge resection for the bulleous part of the paranchyme. MATERIALS AND METHODS Statistically compared variables between the 2 groups were age, sex, symptoms, smoking status, number of previous pneumothorax episodes, surgical indication, bleb number, estimated blood loss, intraoperative complication, duration of the surgery, conversion to open surgery, postoperative drainage amount, chest tube removal time, length of hospital stay, morbidity, mortality, duration of narcotic analgesic usage, pain according to Visual Analog Scale evaluation, follow-up period, and postoperative recurrence. RESULTS The medical records of 88 patients undergoing surgery between 2013 and 2017 were reviewed retrospectively. The pleural abrasion group was superior to the pleurectomy group in terms of operation time, drainage volume, time to drain removal, hospital stay, and Visual Analog Scale pain score on postoperative day 0. Statistically, there was no difference between the pleural abrasion group and the pleurectomy group in the recurrence rates after operation (2.0% vs. 2.5%, respectively; P=0.89). CONCLUSIONS Thoracoscopic pleural abrasion is safer than apical pleurectomy and is associated with the same pneumothorax recurrence rate.
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Vuong NL, Elshafay A, Thao LP, Abdalla AR, Mohyeldin IA, Elsabaa K, Omran ES, Yu F, Hirayama K, Huy NT. Efficacy of treatments in primary spontaneous pneumothorax: A systematic review and network meta-analysis of randomized clinical trials. Respir Med 2018; 137:152-166. [PMID: 29605200 DOI: 10.1016/j.rmed.2018.03.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 02/03/2018] [Accepted: 03/05/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Primary spontaneous pneumothorax (PSP) remains a significant global health problem. Despite general agreement, an official algorithm for the management of PSP still does not exist. OBJECTIVES Evaluating the efficacy of all available treatments in PSP. METHODS A systematic search of 12 electronic databases was performed to identify all randomized controlled trials (RCTs) of any treatments in PSP. The primary endpoint was recurrence incidence; secondary were an immediate success, complication and hospitalization days. All available outcomes were included in frequentist network meta-analysis. RESULTS 4262 patients of 29 RCTs were included. In patients with first episode of PSP, video-assisted thoracoscopic surgery (VATS), tube drainage and aspiration had no significant difference regarding recurrence. Chemical pleurodesis significantly reduced the recurrent incidence of 46% compared with aspiration and 54% compared with tube drainage. VATS and aspiration significantly decreased hospitalization days compared with tube drainage. In patients with recurrent or persistent PSP, thoracotomy with mechanical pleurodesis has a higher rank than VATS with or without pleurodesis in preventing recurrence, with no significant difference. VATS alone significantly reduced complications compared with all others treatments, except thoracotomy with abrasion. CONCLUSIONS Aspiration and tube drainage have no significant difference in treating patients with first episode of PSP regarding recurrence. Aspiration reduced hospitalization days when compared with tube drainage. Thoracotomy with mechanical pleurodesis and VATS with or without pleurodesis are not significantly different in preventing recurrence in patients with recurrent or persistent PSP. VATS alone reduced complications compared with others treatments except for thoracotomy with abrasion.
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Affiliation(s)
- Nguyen Lam Vuong
- Department of Cardiovascular and Thoracic Surgery, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, 70000, Viet Nam; Department of Medical Statistic and Informatics, Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, 70000, Viet Nam.
| | | | - Le Phuong Thao
- Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, 70000, Viet Nam.
| | | | | | - Khaled Elsabaa
- Faculty of Medicine, Al-Azhar University, Cairo, 11884, Egypt.
| | - Esraa Salah Omran
- Kasr Al-Aini School of Medicine, Cairo University, Cairo, 44523, Egypt.
| | - Fuxun Yu
- Guizhou Provincial People's Hospital, Guiyang, China.
| | - Kenji Hirayama
- Department of Immunogenetics, Institute of Tropical Medicine (NEKKEN), Graduate School of Biomedical Sciences, Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan.
| | - Nguyen Tien Huy
- Evidence Based Medicine Research Group & Faculty of Applied Sciences, Ton Duc Thang University, Ho Chi Minh City, Viet Nam; Department of Clinical Product Development, Institute of Tropical Medicine (NEKKEN), Leading Graduate School Program, and Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan.
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Aguinagalde B, Aranda JL, Busca P, Martínez I, Royo I, Zabaleta J. SECT Clinical practice guideline on the management of patients with spontaneous pneumothorax. Cir Esp 2017; 96:3-11. [PMID: 29248330 DOI: 10.1016/j.ciresp.2017.11.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 09/13/2017] [Accepted: 11/06/2017] [Indexed: 11/16/2022]
Abstract
This clinical practice guideline (CPG) emerges as an initiative of the scientific committee of the Spanish Society of Thoracic Surgery. We formulated PICO (patient, intervention, comparison, and outcome) questions on various aspects of spontaneous pneumothorax. For the evaluation of the quality of evidence and preparation of recommendations we followed the guidelines of the Grading of recommendations, Assessment, Development and Evaluation (GRADE) working group.
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Affiliation(s)
- Borja Aguinagalde
- Hospital Universitario Donostia, Donostia-San Sebastián, Guipúzcoa, España.
| | | | - Pablo Busca
- Hospital Universitario Donostia, Donostia-San Sebastián, Guipúzcoa, España
| | - Ivan Martínez
- Hospital Universitario 12 de Octubre, Madrid, España
| | - Iñigo Royo
- Hospital Universitario Miguel Servet, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - Jon Zabaleta
- Hospital Universitario Donostia, Donostia-San Sebastián, Guipúzcoa, España
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Zhang Z, Du L, Feng H, Liang C, Liu D. Pleural abrasion should not routinely preferred in treatment of primary spontaneous pneumothorax. J Thorac Dis 2017; 9:1119-1125. [PMID: 28523168 DOI: 10.21037/jtd.2017.03.124] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The aim of this study was to find out whether thoracoscopic bullectomy with pleural abrasion (BLPA) could lower the recurrence ratio in primary spontaneous pneumothorax (PSP) patients compared with bullectomy alone. METHODS All PSP patients who underwent video assisted thoracoscopy (VATS) bullectomy (120 bullectomy cases) or BLPA (225 BLPA cases) in our department between 2008.1 and 2013.12 were retrospectively reviewed. Clinical data, perioperative data, and follow-up information were collected. Propensity score analysis was used in balancing preoperative factors between groups. RESULTS Three hundred and forty five patients (283 men and 62 women) with an average age of 27 (27.32±11.41) years old underwent 120 bullectomy and 225 BLPA in this study. There was no mortality or significant complication in both groups. More postoperative drainage (1,170.66±904.02 vs. 528.38±491.49, P<0.01), longer chest tube removal days (6.59±4.29 vs. 4.76±2.67, P<0.01), and more medical cost (4,703.86±1,526.31 vs. 4,204.64±1,203.90, P<0.01) were observed in BLPA group. Significant difference (P=0.02) existed in recurrence rate between BLPA group (3/225, 1.3%) and bullectomy group (7/120, 5.8%). After propensity score match, 114 patients were included in both bullectomy and BLPA groups. More postoperative drainage (1,280.18±1,071.04 vs. 523.55±484.79, P<0.01), longer chest tube removal days (6.53±4.16 vs. 4.69±2.63, P<0.01), and more medical cost (4,700.69±1,591.56 vs. 4,211.45±1,207.7, P<0.01) were observed in BLPA group. There was no significant recurrence difference between BLPA group and bullectomy group (2.6% vs. 5.3%, P=0.30). CONCLUSIONS Compared with bullectomy, BLPA could provide similar recurrence for PSP patients, but at the price of longer operation days, longer chest tube removal days, and more medical cost, and should not be performed in PSP patients.
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Affiliation(s)
- Zhenrong Zhang
- Department of General Thoracic Surgery, China Japan Friendship Hospital, Beijing 100029, China
| | - Lanfang Du
- Department of Emergency, Peking University Third Hospital, Beijing 100191, China
| | - Hongxiang Feng
- Department of General Thoracic Surgery, China Japan Friendship Hospital, Beijing 100029, China
| | - Chaoyang Liang
- Department of General Thoracic Surgery, China Japan Friendship Hospital, Beijing 100029, China
| | - Deruo Liu
- Department of General Thoracic Surgery, China Japan Friendship Hospital, Beijing 100029, China
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Puri V. Challenging dicta in thoracic surgery. J Thorac Cardiovasc Surg 2017; 153:e119-e120. [PMID: 28274554 DOI: 10.1016/j.jtcvs.2017.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 02/06/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Varun Puri
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Mo.
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Guo Z, Li S, Yin W, He J. Implementation of a novel enhanced recovery after surgery program in thoracoscopic bilateral bullectomy. J Thorac Cardiovasc Surg 2016; 153:e115-e118. [PMID: 27923484 DOI: 10.1016/j.jtcvs.2016.10.058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 10/17/2016] [Accepted: 10/20/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Zhihua Guo
- Department of Thoracic Surgery, First Affiliated Hospital of Guangzhou Medical University; Guangzhou Research Institute of Respiratory Disease; and Key cite of National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Shuben Li
- Department of Thoracic Surgery, First Affiliated Hospital of Guangzhou Medical University; Guangzhou Research Institute of Respiratory Disease; and Key cite of National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Weiqiang Yin
- Department of Thoracic Surgery, First Affiliated Hospital of Guangzhou Medical University; Guangzhou Research Institute of Respiratory Disease; and Key cite of National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Jianxing He
- Department of Thoracic Surgery, First Affiliated Hospital of Guangzhou Medical University; Guangzhou Research Institute of Respiratory Disease; and Key cite of National Clinical Research Center for Respiratory Disease, Guangzhou, China.
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Nakayama T, Takahashi Y, Uehara H, Matsutani N, Kawamura M. Outcome and risk factors of recurrence after thoracoscopic bullectomy in young adults with primary spontaneous pneumothorax. Surg Today 2016; 47:859-864. [PMID: 27909813 DOI: 10.1007/s00595-016-1452-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 11/01/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE To investigate the risk factors of recurrence of pneumothorax following thoracoscopic bullectomy in young adults. METHODS Between January, 2005 and September, 2015, 167 patients aged ≤40 years underwent initial thoracoscopic bullectomy for primary spontaneous pneumothorax (PSP) at our hospital. Recurrence-free probability was calculated from the date of surgery to recurrence or last follow-up, using the Kaplan-Meier method. RESULTS Sixteen (9.6%) of the 167 patients suffered a recurrence (collective total, 16 recurrences). The recurrence-free intervals were 3-107 months (median 25.8 months), and the 5-year recurrence-free probability was 85.9%. Multivariate Cox analysis demonstrated that age ≤23 years (p = 0.029) and a history of ipsilateral pneumothorax before surgery (p = 0.029) were significantly associated with higher risk of recurrence. The 5-year recurrence-free probability was 72.3% for patients aged ≤23 years and a history of ipsilateral pneumothorax before surgery and 94.1% for those with neither of these factors (p = 0.001). Recurrence developed within 3 years after surgery in 14 of the 16 patients. CONCLUSIONS Patients ≤23 years of age with a history of ipsilateral pneumothorax before surgery are at significantly high risk of its recurrence, frequently within 3 years; thus, the risk of postoperative recurrence of a pneumothorax must be kept in mind.
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Affiliation(s)
- Takashi Nakayama
- Department of General Thoracic Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8606, Japan.
| | - Yusuke Takahashi
- Department of General Thoracic Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8606, Japan
| | - Hirofumi Uehara
- Department of General Thoracic Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8606, Japan
| | - Noriyuki Matsutani
- Department of General Thoracic Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8606, Japan
| | - Masafumi Kawamura
- Department of General Thoracic Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8606, Japan
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Optimal surgical technique in spontaneous pneumothorax: a systematic review and meta-analysis. J Surg Res 2016; 210:32-46. [PMID: 28457339 DOI: 10.1016/j.jss.2016.10.024] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 10/16/2016] [Accepted: 10/26/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Numerous thoracoscopic techniques have been used in the management of primary spontaneous pneumothorax (PSP), including wedge resection, pleurectomy, pleural abrasion, chemical pleurodesis, and staple line covering. The purpose of this systematic review was to compare outcomes for the most commonly reported techniques. MATERIALS AND METHODS A systematic literature search looking at pneumothorax recurrence rate, length of stay, and chest tube duration after surgery was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the PubMed database. RESULTS Fifty-one unique studies comprised of 6907 patients published between January 1988 and June 2015 were identified. Heterogeneity among effect sizes was significant for all outcomes. The lowest recurrence rates were observed in the wedge resection + chemical pleurodesis (1.7%; 95% confidence interval [CI], 1.0%-2.7%) and the wedge resection + pleural abrasion + chemical pleurodesis (2.8%; 95% CI, 1.7%-4.7%) groups. The shortest chest tube duration and length of stay were observed in the wedge resection + staple line covering ± other group (2.1 d; 95% CI, 1.4-2.9 and 3.3 d; 95% CI, 2.6-4.0, respectively). CONCLUSIONS The variability in reported outcomes and the lack of published multicenter randomized controlled trials highlights a need for more robust investigations into the optimal surgical technique in the management of PSP. Based on the limited quality studies available, this systematic review favors wedge resection + chemical pleurodesis and wedge resection + pleural abrasion + chemical pleurodesis in terms of recurrence rate after surgery for PSP.
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Learning curve of single-incision thoracoscopic surgery for primary spontaneous pneumothorax. Surg Endosc 2016; 31:1680-1687. [PMID: 27515837 DOI: 10.1007/s00464-016-5158-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 07/25/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Single-incision thoracoscopic surgery (SITS) requires extensive time and practice to achieve satisfactory technical skills. The aim of this study was to evaluate the learning curves of SITS for primary spontaneous pneumothorax (PSP). METHODS This study included a total of 274 consecutive patients who underwent PSP surgery by a single operator between May 2011 and February 2014. During this period, SITS was applied as a routine approach. Learning curves were made by the cumulative sum (CUSUM) method using the number of cases and four surgical technique-related factors, including operation time, postoperative complication, non-SITS rate, and ipsilateral PSP recurrence. RESULTS Among the 274 patients, 16 patients who were presented with a previous 3-port wound scar or inadequate chest tube site before surgery were not eligible for SITS. Hence, SITS was attempted on 258 patients and performed successfully in 251 patients. For these successful SITS patients, the mean age was 22.9 ± 8.1 years, the mean operation time was 65.6 ± 22.2 min, the mean chest tube indwelling time was 1.5 ± 1.1 days, and the mean postoperative hospital stay was 1.7 ± 1.1 days. The mean operation time decreased from 84.0 to 47.6 min when a comparison was made between patients operated in the initial 6 months and the last 6 months of the study period. As revealed by the CUSUM technique, more than 50 % of the cases experienced an operation time of <70 min after the first 92 cases. After 57 cases, the postoperative complication rate was maintained at <5 %. The non-SITS rate was achieved to be lower than 5 % after 112 cases. The ipsilateral PSP recurrence rate was maintained at below 8 % after 102 cases. CONCLUSIONS Although PSP is the most applicable scenario for the beginner of SITS, at least 100 cases of experience are needed to achieve optimal technical level.
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Transareolar pulmonary bullectomy for primary spontaneous pneumothorax. J Thorac Cardiovasc Surg 2016; 152:999-1005. [PMID: 27496616 DOI: 10.1016/j.jtcvs.2016.06.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Revised: 05/11/2016] [Accepted: 06/19/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Conventional 3-port video-assisted thoracoscopic surgery is the classic approach for the diagnosis and treatment of primary spontaneous pneumothorax. Transareolar pulmonary bullectomy rarely has been attempted. This study aimed to evaluate the feasibility and safety of this novel minimally invasive technique in managing primary spontaneous pneumothorax. METHODS From January 2013 to December 2014, a total of 112 male patients with primary spontaneous pneumothorax underwent transareolar pulmonary bullectomy by use of a 5-mm thoracoscope. RESULTS All procedures were performed successfully, with a mean operating time of 26.5 minutes. The mean length of transareolar incision for the main operation was 2.0 ± 0.2 cm, the mean length of incision for the camera port was 0.6 ± 0.1 cm, and the mean postoperative cosmetic score was 3.0 ± 0.8. All patients regained consciousness rapidly after surgery. One hundred seven patients (95.5%) were discharged on postoperative day 2 or 3, with the remainder discharged on postoperative day 4 or 5. Postoperative complications were minor. At 6 months postoperatively, there was no obvious surgical scar on the chest wall, and no patient complained of postoperative pain. No recurrent symptoms were observed. One-year follow-up revealed an excellent cosmetic result and degree of satisfaction. CONCLUSIONS Transareolar pulmonary bullectomy is a safe and effective therapeutic procedure for primary spontaneous pneumothorax caused by pulmonary bullae. The incision is hidden in the areola with excellent cosmetic effects. This novel procedure shows promise as a treatment of primary spontaneous pneumothorax.
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Spontaneous ventilation anaesthesia: total intravenous anaesthesia with local anaesthesia or thoracic epidural anaesthesia for thoracoscopic bullectomy. Eur J Cardiothorac Surg 2016; 50:927-932. [DOI: 10.1093/ejcts/ezw209] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 05/18/2016] [Indexed: 11/14/2022] Open
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Han KN, Kim HK, Lee HJ, Lee DK, Kim H, Lim SH, Choi YH. Single-port thoracoscopic surgery for pneumothorax under two-lung ventilation with carbon dioxide insufflation. J Thorac Dis 2016; 8:1080-6. [PMID: 27293823 DOI: 10.21037/jtd.2016.03.95] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The development of single-port thoracoscopic surgery and two-lung ventilation reduced the invasiveness of minor thoracic surgery. This study aimed to evaluate the feasibility and safety of single-port thoracoscopic bleb resection for primary spontaneous pneumothorax using two-lung ventilation with carbon dioxide insufflation. METHODS Between February 2009 and May 2014, 130 patients underwent single-port thoracoscopic bleb resection under two-lung ventilation with carbon dioxide insufflation. Access was gained using a commercial multiple-access single port through a 2.5-cm incision; carbon dioxide gas was insufflated through a port channel. A 5-mm thoracoscope, articulating endoscopic devices, and flexible endoscopic staplers were introduced through a multiple-access single port for bulla resection. RESULTS The mean time from endotracheal intubation to incision was 29.2±7.8 minutes, the mean operative time was 30.9±8.2 minutes, and the mean total anesthetic time was 75.5±14.4 minutes. There were no anesthesia-related complications or wound problems. The chest drain was removed after a mean of 3.7±1.4 days and patients were discharged without complications 4.8±1.5 days from the operative day. During a mean 7.5±10.1 months of follow-up, there were five recurrences (3.8%) in operated thorax. CONCLUSIONS The anesthetic strategy of single-lumen intubation with carbon dioxide gas insufflation can be a safe and feasible option for single-port thoracoscopic bulla resection as it represents the least invasive surgical option with the potential advantages of reducing operative time and one-lung ventilation-related complications without diminishing surgical outcomes.
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Affiliation(s)
- Kook Nam Han
- 1 Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea ; 2 Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hyun Koo Kim
- 1 Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea ; 2 Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hyun Joo Lee
- 1 Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea ; 2 Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Dong Kyu Lee
- 1 Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea ; 2 Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Heezoo Kim
- 1 Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea ; 2 Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Sang Ho Lim
- 1 Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea ; 2 Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Young Ho Choi
- 1 Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea ; 2 Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Republic of Korea
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Guo Z, Yin W, Zhang X, Xu X, Liu H, Shao W, Liu J, Chen H, He J. Primary spontaneous pneumothorax: simultaneous treatment by bilateral non-intubated videothoracoscopy. Interact Cardiovasc Thorac Surg 2016; 23:196-201. [PMID: 27165732 DOI: 10.1093/icvts/ivw123] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 04/09/2016] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Through a retrospective study, we assessed the feasibility and safety of simultaneous bilateral thoracoscopic wedge resection of blebs or bullae for the treatment of primary spontaneous pneumothorax (PSP) under thoracic epidural anaesthesia with spontaneous ventilation. METHODS This retrospective analysis involved a cohort of 37 consecutive patients undergoing simultaneous bilateral thoracoscopic bullectomy under spontaneous ventilation thoracic epidural anaesthesia (n = 15) or intubated general anaesthesia (n = 22) between July 2011 and September 2015. The perioperative data, short-term outcomes and recurrence rates of the two groups were compared. RESULTS The two groups had comparable preoperative demographic profiles. There were no conversions to thoracotomy or intubated single-lung ventilation. The peak end-tidal carbon dioxide in the non-intubated group was significantly higher than that in the intubated group (mean: 48 vs 34 mmHg, P < 0.001). Both groups had comparable surgical duration, blood loss and lowest intraoperative pulse oxygen saturation level. Postoperatively, the two groups had comparable chest tube duration, volume of fluid administration, length of hospital stay and complication rates. No mortality occurred. The total anaesthesia cost in non-intubated group was significantly lower (mean: CNY 4584 vs 5649, P = 0.016). The mean follow-up was 23.6 ± 12.9 months in the non-intubated group and 21.1 ± 13.4 months in the intubated group. Two recurrent pneumothoraxes in 2 patients were observed after surgical procedures for PSP. One recurrence developed in the non-intubated group (7%) and one in the intubated group (5%). CONCLUSIONS Simultaneous bilateral non-intubated thoracoscopic bullectomy is not only well tolerated and technically feasible but also a safe alternative for selected patients with simultaneous bilateral PSP or with high risk of contralateral recurrence.
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Affiliation(s)
- Zhihua Guo
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China Guangzhou Institute of Respiratory Disease and China State Key Laboratory of Respiratory Disease, Guangzhou, China National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Weiqiang Yin
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China Guangzhou Institute of Respiratory Disease and China State Key Laboratory of Respiratory Disease, Guangzhou, China National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Xin Zhang
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China Guangzhou Institute of Respiratory Disease and China State Key Laboratory of Respiratory Disease, Guangzhou, China National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Xin Xu
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China Guangzhou Institute of Respiratory Disease and China State Key Laboratory of Respiratory Disease, Guangzhou, China National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Hui Liu
- Department of Anesthesiology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wenlong Shao
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China Guangzhou Institute of Respiratory Disease and China State Key Laboratory of Respiratory Disease, Guangzhou, China National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Jun Liu
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China Guangzhou Institute of Respiratory Disease and China State Key Laboratory of Respiratory Disease, Guangzhou, China National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Hanzhang Chen
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China Guangzhou Institute of Respiratory Disease and China State Key Laboratory of Respiratory Disease, Guangzhou, China National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Jianxing He
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China Guangzhou Institute of Respiratory Disease and China State Key Laboratory of Respiratory Disease, Guangzhou, China National Clinical Research Center for Respiratory Disease, Guangzhou, China
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Huang H, Ji H, Tian H. Risk factors for recurrence of primary spontaneous pneumothorax after thoracoscopic surgery. Biosci Trends 2016; 9:193-7. [PMID: 26166373 DOI: 10.5582/bst.2015.01070] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Primary spontaneous pneumothorax recurs at a certain rate after thoracoscopic surgery, and risk factors for that recurrence are in question. The medical records of 248 patients with primary spontaneous pneumothorax who were followed for more than 2 years after thoracoscopic surgery were reviewed and retrospectively analyzed. Univariate and multivariate binary logistic regression analysis were used to identify possible risk factors. Twelve patients experienced the recurrence of primary spontaneous pneumothorax. Patients who experienced the recurrence of primary spontaneous pneumothorax were younger than patients who experienced no recurrence. A larger proportion of the patients who experienced recurrence did not undergo pleurodesis. The variables age, height, weight, body mass index, duration of air leakage, and pleurodesis (performed or not) with a p value less than 0.2 in univariate analysis were entered in multivariate analysis. A younger age and not undergoing pleurodesis were associated with a higher risk of postoperative ipsilateral recurrence of primary spontaneous pneumothorax. Not undergoing pleurodesis and a younger age are possible risk factors for recurrence of primary spontaneous pneumothorax after thoracoscopic surgery. Thoracic surgeons should pay more attention to pleurodesis, especially in younger patients.
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Affiliation(s)
- Haibo Huang
- Department of Thoracic Surgery, Qilu Hospital, Medical College of Shandong University
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Ota H, Kawai H, Kuriyama S. The Presence of a Reticulated Trabecula-Like Structure Increases the Risk for the Recurrence of Primary Spontaneous Pneumothorax after Thoracoscopic Bullectomy. Ann Thorac Cardiovasc Surg 2016; 22:139-45. [PMID: 26875751 DOI: 10.5761/atcs.oa.15-00306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Deteriorated alveolar structure at the base of blebs and bullae is known as the reticulated trabecula-like structure. Its clinical significance in primary spontaneous pneumothorax (PSP) remains unclear. This study aimed to investigate the impact of the structure on recurrence of PSP after video-assisted thoracoscopic surgery (VATS) bullectomy. METHODS Between April 2010 and March 2014, 80 cases of PSP in 76 patients who underwent VATS bullectomy using endoscopic staplers were included. The staple line was covered with polyglycolic acid sheets and fibrin glue. Cases were assigned to a normal alveolar structure (NAS) group (n = 54) and a reticulated trabecula-like structure (RT) group (n = 26) based on the histological analysis. Factors associated with recurrence were analysed using logistic regression. RESULTS The reticulated trabecula-like structure was significantly related to apical lung blebs. The recurrence rate of PSP was significantly higher in the RT group than in the NAS group (38.5% vs. 3.7%; P <0.001). On multivariate analysis, the reticulated trabecula-like structure was an independent factor for recurrence of PSP after VATS bullectomy. CONCLUSION The change of alveolar structure at the base of apical lung blebs would increase the risk for recurrence of PSP after VATS bullectomy.
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Affiliation(s)
- Hideki Ota
- Department of Thoracic Surgery, Akita Red Cross Hospital, Akita, Akita, Japan
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The effect of pleural abrasion on the treatment of primary spontaneous pneumothorax: a systematic review of randomized controlled trials. PLoS One 2015; 10:e0127857. [PMID: 26042737 PMCID: PMC4456155 DOI: 10.1371/journal.pone.0127857] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 04/21/2015] [Indexed: 11/19/2022] Open
Abstract
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.
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