Risk factors for postoperative recurrence of spontaneous pneumothorax treated by video-assisted thoracoscopic surgery†

Lessons from short chest drain management for primary spontaneous pneumothorax

OBJECTIVES

Video-assisted thoracic surgery (VATS) bullectomy is the mainstay treatment for primary spontaneous pneumothorax (PSP) but we encounter patients with pain due to chest tube. This study investigated the postoperative outcomes of shortened silicone drain as a chest tube after VATS bullectomy to reduce pain.

METHODS

The current study included patients aged < 30 years who underwent VATS bullectomy for PSP. Patients with normal intrathoracic lengths of the silicone drain placed in a loop at the apex toward the diaphragm were categorized as Group L, whereas those with the silicone drain shortened to approximately 10 cm and placed toward the apex were classified as Group S. Postoperative pain evaluated using a numerical rating scale (NRS) and other perioperative outcomes were compared between the groups.

RESULTS

Altogether, 43 patients were included, with 22 in Group L and 21 in Group S, respectively. The NRS before chest tube removal was significantly lower in Group S (mean, 2.1) than in Group L (4.4; p = 0.001). In Group L, 4 patients (p = 0.017) required early chest tube removal than expected due to severe pain whereas none in Group S required this intervention; additionally, more patients needed additional analgesics than in Group S (p = 0.003).

CONCLUSION

In VATS bullectomy for PSP, the pain intensity could be reduced by shortening the intrathoracic length of the silicone drain, compared to a longer intrathoracic length of the silicon drain. Our findings contribute to the establishment of optimal postoperative management of general thoracic surgery.

Spontaneous Pneumothorax in a Healthy Young Woman: Discussion About Treatment Options

A spontaneous pneumothorax, a potentially life-threatening condition, is a disease process in which air enters the space between the visceral and parietal pleural of the lung, thus increasing the pressures in that space. It can be diagnosed by both physical exam and radiographic testing. In this case, we present a 21-year-old, otherwise healthy woman who presented with sudden, sharp shoulder pain and chest tightness and was diagnosed with her first, spontaneous pneumothorax. We further discuss the diagnosis and treatment options for a first-time spontaneous pneumothorax.

Efficacy of mesh coverage in surgical bullectomy for primary spontaneous pneumothorax: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Thoracic surgeons are now adopting a new method of using a mesh covering to reduce recurrence in surgical pleurodesis for pneumothorax. We aimed to review the literature and compare the outcomes of using mesh covering as an additional procedure during surgical pleurodesis.

METHODS

A comprehensive search was performed from inception to October 2022 on PubMed, Embase, Cochrane and Scopus. Randomised controlled trials (RCTs) and observational cohort studies (OCSs) comparing the use of mesh coverage, and different materials were included. Data were extracted to compare recurrence and other outcomes using a random effect model.

RESULTS

23 studies consisting of 2 RCTs and 21 OCSs totalling 5092 patients were included. Patients with a mesh had a significantly lower recurrence (OR = 0.22, 95% CI 0.12-0.42, p < 0.0001) and a shorter duration of chest tube drainage (SMD = -0.74 days, 95% CI -0.28 to -1.20, p < 0.0001) but no significant difference in the length of operation. The use of polyglycolic acid (PGA) and vicryl mesh was associated with a significantly shorter duration of chest tube drainage [(PGA, SMD = 0.83 days, 95% CI 0.14-1.52, p < 0.0001), (vicryl, SMD = 1.06 days, 95% CI 0.71-2.82, p = 0.0005)]. They also had a shorter post-operative length of stay than oxidized regenerative cellulose (ORC) but this was not statistically significant.

CONCLUSION

The use of a mesh material reduced the incidence of post-operative air leaks in the short term and the recurrence rate in the long term. Some mesh materials such as PGA and vicryl performed better than other materials.

Effectiveness of Video-Assisted Thoracoscopic Surgery with Bullectomy and Partial Pleurectomy in the Treatment of Primary Spontaneous Pneumothorax-A Retrospective Long-Term Single-Center Analysis

Background: Video-assisted thoracoscopic surgery (VATS) with bullectomy and partial pleurectomy (VBPP) is an increasingly used and well-established surgical treatment for primary spontaneous pneumothorax (PSP). However, reports on its effectiveness and long-term outcomes are limited. The aim of this study was to assess and compare long-term recurrence rates following VBPP and chest tube (CT) treatment and to identify potential risk factors for disease recurrence in patients with PSP. Methods: A total of 116 patients treated either by VBPP or CT were included in this study. Long-term recurrence rates and associations between clinical parameters and recurrence of pneumothorax were analyzed. Results: Sixty-two patients (53.4%) underwent VBPP, whereas 54 (46.6%) patients underwent CT treatment only. During a median follow-up period of 76.5 months, VBPP patients experienced a significantly lower recurrence rate compared to CT patients (6/62 vs. 35/54; p < 0.0001). CT treatment (VBPP vs. CT; p < 0.001) and a large initial pneumothorax size (Collins < 4 vs. Collins ≥ 4; p = 0.018) were independent risk factors for pneumothorax recurrence. Conclusion: VBPP is an effective and safe surgical treatment for PSP. Therefore, patients with a large pneumothorax size might benefit from VBPP, as they are at high risk for disease recurrence.

Early Postoperative Pneumothorax Might Not Be 'True' Recurrence

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.

Recurrence Rates After Video-Assisted Thoracoscopic Surgery for Spontaneous Pneumothorax

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.

Male adolescents with contralateral blebs undergoing surgery for primary spontaneous pneumothorax may benefit from simultaneous contralateral blebectomies

BACKGROUND

In adults with primary spontaneous pneumothorax (PSP), contralateral recurrence occurs in about 25-28% when there are asymptomatic blebs. How to treat contralateral recurrence of PSP in pediatric populations remains controversial. This study evaluated the outcomes of excising contralateral blebs to prevent recurrence in adolescents being operated on for PSP under the same anesthesia.

METHODS

One hundred thirty-two male PSP patients under age 19 were surgically treated in a single institution between January 2008 and December 2016. Thoracoscopic blebectomies with pleurodesis were performed in all patients. The patients were categorized into those with contralateral blebs receiving one-stage bilateral surgeries (32 patients), those with contralateral blebs only receiving unilateral surgeries (40 patients), and those without contralateral blebs only receiving unilateral surgeries (60 patients). Perioperative details and outcomes were retrospectively analyzed.

RESULTS

Significant differences in contralateral recurrence rate were found among the three groups (0%, 30%, and 1%, respectively; P < 0.001). Multivariate analysis showed that being under 16.5 years old was a risk factor for overall recurrence (Hazard ratio [HR] 2.81, 95% confidence interval [CI] 1.08-7.30, P = 0.034). Moreover, patients who had contralateral blebs and only received unilateral surgery were at greater risk of overall recurrence (HR 6.06, 95% CI 1.77-20.75, P = 0.004). Kaplan-Meier analysis showed that contralateral and overall recurrence-free survival differed among the three groups (P < 0.0001, P = 0.0002).

CONCLUSIONS

Although younger male PSP adolescents treated with surgery were more likely to have postoperative recurrences, the performance of simultaneous contralateral blebectomies in those receiving one-stage bilateral surgeries significantly reduced future contralateral recurrence without compromising patient safety.

A systematic review and meta-analysis of video-assisted thoracoscopic surgery treating spontaneous pneumothorax

Background

With the adoption of high-tech thoracoscopic surgical instruments, video-assisted thoracoscopic surgery (VATS) has gradually replaced traditional thoracotomy and is used in the clinical treatment of spontaneous pneumothorax.

Methods

The composite logic retrieval and Boolean logic retrieval methods were adopted for this meta-analysis. Databases such as PubMed, Medline, Cochrane Library, CNKI, Wanfang, VIP, and Google Scholar were searched using the combination of search terms “Video-assisted thoracoscopic surgery”, “spontaneous pneumothorax”, and “thoracotomy”. Literatures which used video-assisted thoracoscopic surgery for spontaneous pneumothorax as the experimental group were screened. The software RevMan 5.3 provided by the Cochrane system was employed for meta-analysis.

Results

A total of 12 studies were included. After the meta-analysis, heterogeneity testing of the operation time in 8 studies showed that Tau² =29.99, Chi² =16.99, degrees of freedom (df) =7, I²=59%>50%, and the operation time of participants in the experimental group was considerably inferior to that of control group. The mean difference (MD) was −31.02, 95% confidence interval (95% CI: −36.07 to −25.97), Z=12.03, P<0.0001. The heterogeneity test of the length of hospital stay in 9 studies showed that Tau² =4.41, Chi² =122.58, df =8, I²=59%>50%, P<0.01, and the length of hospital stay of participants in the experimental group was remarkably shorter than that of the control group. The MD was −7.29, 95% CI: (−8.76 to −5.82), Z=9.74, and P<0.01. The heterogeneity test of the bleeding volume in 6 studies showed that Tau² =191.74, Chi² =27.65, df =5, I²=82%>50%, P<0.01, and the bleeding volume of participants in the experimental group was remarkably lower in contrast to that of the control group. The MD was −65.48, 95% CI: (−77.84 to −53.13), Z=10.39, and P<0.01. The heterogeneity test of the chest tube removal time in 7 studies showed that Tau² =0.29, Chi² =28.27, df =6, I²=79%>50%, P<0.05, and the chest tube removal time of participants in the experimental group was substantially lower in contrast to that of the control group. The MD was −3.10, 95% CI: (−3.56 to −2.64), Z=13.30, P<0.01.

Discussion

This meta-analysis confirmed that VATS for spontaneous pneumothorax is better than other surgical methods.

Analysis of pneumothorax recurrence risk factors in 843 patients who underwent videothoracoscopy for primary spontaneous pneumothorax: results of a multicentric study

OBJECTIVES

Risk factors for pneumothorax recurrence after videothoracoscopy for primary spontaneous pneumothorax are still being debated. The goal of this study was to assess whether the pleurodesis technique and other variables are possibly associated with the postoperative ipsilateral recurrence of pneumothorax.

METHODS

We retrospectively collected data of 1178 consecutive ≤40-year-old patients who underwent videothoracoscopy for primary spontaneous pneumothorax in 9 centres between 2007 and 2017. We excluded patients with hybrid pleurodesis and/or incomplete follow-up, leaving for analysis 843 cases [80% men; median age (interquartile range) 22 (18-28) years]. Univariable and multivariable analyses were performed by logistic regression and tested by Cox regression model to assess factors related to ipsilateral pneumothorax recurrence including age, gender, body mass index, smoking habit, cannabis smoking, respiratory comorbidity, dystrophic severity score, surgical indication, videothoracoscopy port number and side, lung resection, pleurodesis technique and postoperative prolonged air leak (>5 days).

RESULTS

Blebs/bullae resection was performed in 664 (79%) patients. Pleurodesis was achieved by partial pleurectomy in 228 (27%) cases; by pleural electrocauterization in 176 (21%); by pleural abrasion in 121 (14%); and by talc poudrage in 318 (38%). During a median follow-up period of 70.0 months (95% confidence interval 66.6-73.4), pneumothorax recurred in 79 patients (9.4%); among these, 29 underwent redo surgery; 34, chest drain/talc slurry; and 16, clinicoradiological observation. The only independent risk factor for recurrence was postoperative prolonged air leak (P < 0.001) that was significantly related to blebs/bullae resection (P = 0.03).

CONCLUSIONS

In this multicentric series, postoperative ipsilateral pneumothorax recurrence was remarkable and independently related to prolonged postoperative air leak; besides the retrospective study setting, the pleurodesis method did not have an impact on recurrence. To prevent prolonged air leak, blebs/bullae treatment should be accurate and performed only if indicated.

Uniportal approach as an alternative to the three-portal approach to video-assisted thoracic surgery for primary spontaneous pneumothorax

Background

In recent years, uniportal video-assisted thoracic surgery (U-VATS) has been used for primary spontaneous pneumothorax (PSP). This study compared the perioperative outcomes of U-VATS and three-port VATS (3P-VATS) and sought to determine the risk factors for postoperative recurrence.

Methods

From October 2010 to February 2017, 232 patients with PSP undergoing surgical treatment were enrolled in this study. The patients were divided into two groups: U-VATS (n=161) and 3P-VATS (n=71) depending on the period of surgery. Retrospective analysis of the perioperative results and the risk factors for recurrence was performed.

Results

Both the operation time and duration of postoperative drainage were initially longer in the U-VATS group, but the difference gradually decreased such that ultimately there was no significant difference compared to the 3P-VATS group (P=0.10 and P=0.12, respectively). The duration of postoperative hospital stay and postoperative recurrence rate were not different between the two groups (P=0.084 and P=0.44, respectively). By multivariate analysis, the age (HR, 0.42, 95% CI: 0.24−0.72, P<0.01) and number of bullae (single vs. multiple: HR, 0.03, 95% CI: 0.002−0.54, P=0.02) were risk factors for recurrence.

Conclusions

The perioperative results and recurrence rate did not differ between the U-VATS and 3P-VATS groups, thereby demonstrating the non-inferiority of U-VATS. Postoperative risk factors for PSP recurrence were patient age and the number of bullae. Additional treatment may be needed to reduce recurrence in young patients with multiple bullae. Clinical registration number: The Institutional Review Board of Maebashi Red Cross Hospital (no. 2019-21).

Chronic chest pain and paresthesia after video-assisted thoracoscopy for primary pneumothorax

Background

This study aims to identify clinical and surgical risk factors for chronic chest pain and paresthesia after video thoracoscopic surgery for primary spontaneous pneumothorax.

Methods

We retrospectively collected the data of 1,178 consecutive patients <40-years-old undergoing video thoracoscopic surgery for primary spontaneous pneumothorax in 9 Italian centers in 2007–2017. Cases with <2-month follow-up were excluded, leaving 920 patients [80% male; median age: 21 (IQR, 18–27) years] for statistical analysis. The following risk factors for chronic chest pain and chronic paresthesia were assessed by univariable and multivariable Cox regression model: age, gender, cannabis smoking, video thoracoscopy ports number, pleurodesis technique (partial pleurectomy/pleural electrocauterization/pleural abrasion/talc poudrage), chest tube size (24/28 F), postoperative chest tube stay.

Results

Blebs/bullae resection with pleurodesis was performed in 732 (80%) cases; pleurodesis alone in 188 (20%). During a median follow-up of 68 (IQR: 42–95) months, chronic chest pain developed in 8% of patients, chronic chest paresthesia in 22%; 0.5% of patients regularly assumed painkillers. Chronic chest pain was independently associated with partial pleurectomy/pleura abrasion (P<0.001) and postoperative chest tube stay (P=0.019). Chronic chest paresthesia was independently associated with pleurodesis by partial pleurectomy (P<0.001), chest tube stay (P=0.035) and 28 F chest tube (P<0.001).

Conclusions

After video thoracoscopic surgery for primary spontaneous pneumothorax, the incidence of chronic chest pain and paresthesia was significantly lower when pleurodesis was performed by pleural electrocauterization or talc poudrage, and chest tube was removed early. A 24 F chest tube was associated with lower risk of chronic chest paresthesia.

Polyglycolic acid mesh for preventing post-thoracoscopic bullectomy recurrence

PURPOSE

Thoracoscopic bullectomy is a common treatment modality for spontaneous pneumothorax but can result in a high frequency of postoperative recurrent pneumothorax in young patients. This retrospective study compared the recurrence rate of pneumothorax following conventional thoracoscopic bullectomy to that following bullectomy using a low-density polyglycolic acid mesh to cover the staple line.

METHODS

Group A comprised 237 patients who experienced 294 episodes of pneumothorax and underwent thoracoscopic bullectomy alone, and Group B comprised 130 patients who experienced 155 episodes of pneumothorax and underwent bullectomy with polyglycolic acid mesh used to cover the visceral pleura. To compare the postoperative inflammatory response between the two groups, we measured three inflammatory parameters: highest body temperature after surgery, C-reactive protein level on postoperative day 3, and change in eosinophil count from the day before the surgery to postoperative day 3.

RESULTS

The recurrence rate was significantly lower in Group B than in Group A (2.6% vs. 24.8%, P < 0.000001). All three inflammatory parameters were significantly higher in Group B than in Group A.

CONCLUSIONS

Using a polyglycolic acid mesh covering after thoracoscopic bullectomy resulted in acceptable long-term results (recurrence rate: 2.6%). This method was associated with a slightly elevated inflammatory response.

Recurrence of spontaneous pneumothorax six years after VATS pleurectomy: evidence for formation of neopleura

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.

Age and Clinical Presentation for Primary Spontaneous Pneumothorax

Primary spontaneous pneumothorax (PSP) is a commonly known condition due to the accumulation of air in the pleural space in otherwise healthy people, without apparent underlying lung disease. To date, the exact pathogenesis of PSP is unclear, but it still represents a public health issue. We performed a review of the literature concerning the epidemiology of PSP, examining age of onset and presentation symptoms, in order to assess the possible correlation between these characteristics and its occurrence. Data concerning age, signs, and symptoms were collected. For description purposes, information regarding aetiological and anthropomorphic data was also gathered. In total, 265 papers were evaluated. Regarding age of onset, PSP is a disease that can occur in a broad age group with a double cluster (15-30 and 40-45 yr). Regarding symptoms, pain and dyspnoea (in its various forms) are the most described in PSP. Pain was recorded in 69.25% (range, 9-100%) of the population studied, whereas dyspnoea was present in an average of 54.55% (range, 27-77.1%). Tobacco exposure seems to play an important role in the early onset of PSP. Concerning age at presentation, this review highlights that PSP can occur over a broad age range. The literature appears to be consistent in reporting PSP occurrence mostly below 45 years of age. Asymptomatic PSP is an almost unseen entity. Finally, of pollutants, cigarette smoking should be considered as the most significant exogenous risk factor in the development of PSP.

Interpleural distance predicts persistent air leak after initial primary spontaneous pneumothorax

Background

Initial surgical intervention for a first episode of primary spontaneous pneumothorax (PSP) is controversial. However, if air leak persists after initial drainage, surgical treatment is recommended. Therefore, we investigated risk factors for persistent air leak (PAL) in patients with a first episode of PSP.

Methods

We retrospectively analyzed 122 patients with a first episode of PSP between January 2011 and April 2019. PAL was defined as air leak lasting 72 hours or longer. Early admission was defined hospital admission within 24 hours of symptom onset. Three methods were used to estimate pneumothorax size on chest X-rays taken at admission: interpleural distance, apex-cupola distance, and Light index.

Results

Among 122 patients, 55 developed PAL (PAL group) and 67 did not (non-PAL group). The size of pneumothorax was significantly larger in the PAL group than in the non-PAL group in all three methods of assessment (P<0.001). Early hospital admission was significantly associated with PAL (P=0.026). Logistic regression analysis revealed that the odds ratio for PAL per unit increase in pneumothorax size evaluated with the interpleural distance was 1.304 (P<0.001). Multivariate logistic regression analysis showed that interpleural distance at the hilum and early admission (P<0.001, P=0.008, respectively) were independent predictors of PAL in patients with a first episode of PSP.

Conclusions

In our study, we demonstrated that the interpleural distance at the hilum is a simple and effective predictor of PAL in patients with a first episode of PSP. Our data may help decision-making for initial surgical treatment in these patients.

Simultaneous bilateral thoracoscopic blebs excision reduces contralateral recurrence in patients undergoing operation for ipsilateral primary spontaneous pneumothorax

OBJECTIVE

Contralateral recurrence in patients with primary spontaneous pneumothorax is approximately 15%. If positive for blebs, the recurrence rate increases to 26%. This study seeks to determine whether simultaneous contralateral video-assisted thoracic surgery blebs excision would effectively lower the contralateral incidence of pneumothorax in patients undergoing surgery for ipsilateral primary spontaneous pneumothorax.

METHODS

Between January 2009 and December 2015, 335 patients with primary spontaneous pneumothorax, surgically treated in a single institution, were retrospectively studied. The median follow-up was 75 (50-99) months. All patients received video-assisted thoracic surgery blebectomy/bullectomy with pleural abrasions. They were classified into 3 groups: (1) ipsilateral video-assisted thoracic surgery without contralateral blebs/bullae included 142 patients with ipsilateral primary spontaneous pneumothorax without contralateral blebs/bullae only receiving ipsilateral video-assisted thoracic surgery; (2) ipsilateral video-assisted thoracic surgery with contralateral blebs/bullae included 123 patients with ipsilateral primary spontaneous pneumothorax with contralateral blebs/bullae receiving only ipsilateral video-assisted thoracic surgery; and (3) bilateral video-assisted thoracic surgery with contralateral blebs/bullae included 70 patients with ipsilateral primary spontaneous pneumothorax with contralateral blebs/bullae receiving 1-stage bilateral video-assisted thoracic surgery. Demographic data, perioperative details, recurrence patterns, recurrence-free survivals, and risk factors were compared.

RESULTS

The percentage of contralateral recurrence for the ipsilateral video-assisted thoracic surgery without contralateral blebs/bullae, ipsilateral video-assisted thoracic surgery with contralateral blebs/bullae, and bilateral video-assisted thoracic surgery with contralateral blebs/bullae groups differed significantly (0.7%, 14.6%, and 2.9%, respectively; P = .002). Multivariate analysis using the Cox proportional hazard model revealed that age less than 18 years (hazard ratio, 2.71; 95% confidence interval, 1.14-6.44; P = .024) and ipsilateral video-assisted thoracic surgery with contralateral blebs/bullae (hazard ratio, 22.13, 95% confidence interval, 2.96-165, P = .003) were predictors of contralateral recurrence, of which recurrence-free survival was notably different among groups as determined by Kaplan-Meier analysis (P < .0001).

CONCLUSIONS

Simultaneous contralateral blebectomy in patients with primary spontaneous pneumothorax receiving ipsilateral video-assisted thoracic surgery significantly lowered future contralateral recurrence.

Primary spontaneous pneumothorax in children: factors predicting recurrence and contralateral occurrence

BACKGROUND

The risk factors for recurrence in primary spontaneous pneumothorax (PSP) in children are not well known. We aimed to identify possible risk factors, and to evaluate the utility of computerised tomography (CT) scans in predicting future episodes.

METHODS

We reviewed children aged < 18 years admitted to our institution for PSP from 2008 to 2017, excluding those with malignancies. Basic demographic data were extracted. Clinical data collected include pneumothorax laterality, CT results, treatment protocols and recurrences.

RESULTS

63 patients were included, 19 (30.2%) of whom had CT scans. A total of 41 surgeries were performed. The median (interquartile range) age was 15.4 years (14.9-15.9), and body-mass index was 17.9 kg/m² (15.8-19.3). 56 (88.9%) patients were male. Median follow-up duration was 19.8 months (11.6-35.9). Multivariate logistic regression analyses identified surgery in the first episode as a predictor for a subsequent contralateral occurrence (odds ratio [95% confidence interval] 32.026 [1.685-608.518], p = 0.021). No predictors for ipsilateral recurrence were found. CT scans were 76.5% sensitive for bleb detection, and predicted poorly for occurrence (positive predictive value 14.3%, likelihood ratio 1.1).

CONCLUSION

This is the first study demonstrating that surgery at first presentation appears to predict for occurrence of PSP on the contralateral lung. CT appears to be ineffective in detecting blebs and predicting PSP occurrence.

Uniportal VATS technique for primary spontaneous pneumothorax: An analysis of 46 cases

Objective

In the treatment of primary spontaneous pneumothorax (PSP), the influence of safety and applicability of uniportal video assisted thoracoscopic surgery (VATS) bullectomy/blebectomy and pleurectomy method were evaluated in 46 patients.

Methods

Between November 2010 and January 2019, 46 patients (36 males, 10 females; mean age 24.2 years; range 16-36 years) undergoing uniportal video thoracoscopic bullectomy/blebectomy and apical pleurectomy for primary spontaneous pneumothorax were evaluated retrospectively at Canakkale Onsekiz Mart University (COMU). One patient underwent surgery for the second time after three months for contralateral pneumothorax and counted as two different patients, hence forty seven operations were performed in total. The cases were evaluated in terms of age, gender, comorbidity, duration of hospital stay, histopathological diagnosis, postoperative morbidity and mortality.

Results

Right surgical intervention was performed in 20 cases (42.6%) and left surgical intervention in 27 cases (57.6%). A total of 15 (31.9%) surgical operations were performed during the first attack, 30 (63.8%) during the second attack and 2 (4.3%) during third and more attacks. There was prolonged air leakage in all patients operated during the first episode. All cases underwent wedge resection and pleurectomy with endoscopic stapes. None of the patients required thoracotomy. Postoperative drainage period was between 2-7 days (mean: 4.1) and the duration of hospitalization was between three to eight days. Postoperative pain and paraesthesia were observed in eight cases. Prolonged air leakage was observed in five cases.

Conclusion

With video thoracoscopic uniportal technique, not only lung biopsy and resection but also bullectomy/blebectomy and pleurectomy operations can be performed safely in the treatment of PSP. In view of this information, minimally invasive techniques are seen as more advantageous than conventional techniques.

Fate of spontaneous pneumothorax from middle to old age: how to overcome an irritating recurrence?

Background

The causes and treatment of pneumothorax in older patients are different from those in younger patients. However, studies on this topic are limited thus; pneumothorax in older patients is often inadequately managed. The purpose of this research was to investigate the characteristics of pneumothorax in patients over 45 years old, understand patterns of management and factors of recurrence, and propose reasonable guidelines for the treatment of older patients.

Methods

Of 438 consecutive patients with spontaneous pneumothorax between 2013 and 2017, 120 patients were enrolled and divided into two groups: (I) 45-64 years and (II) ≥65 years. Basic demographics, treatment modality, and patterns of surgery/recurrence were described. Clinical variables were compared between groups, and risk factors of recurrence were analyzed using logistic regression.

Results

The study population was divided into group A (younger, n=61) and B (older, n=59). Chest tube drainage was the most common procedure for both groups and chemical pleurodesis was applied more often in B (27% vs. 11%, P=0.03). The length of hospital stay was longer in B (8.8 vs. 5.9 days, P<0.01) but complications and recurrence rate did not differ between groups (P=0.09 and 0.93). The choice of procedures in recurrent pneumothorax was different (P=0.02). Specifically, invasive procedures such as surgery occurred more often in A, but non-invasive procedures occurred more often in B. Multivariate analysis revealed that bullae/blebs (odds ratio=5.57) and emphysema (odds ratio=3.83) showed a positive association with recurrence whereas surgery (odds ratio=0.11) was negative.

Conclusions

Radiological findings of emphysema or bullae/blebs are risk factors for recurrence of pneumothorax in elderly patients. Surgery in selected patients is an effective method for decreasing the recurrence rate.

Video-Assisted Thoracic Surgery (VATS) Talc Pleurodesis Versus Pleurectomy for Primary Spontaneous Pneumothorax: A Large Single-Centre Study with No Conversion

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.

Elective surgery treatment in patient living in rural area with history of recurrent primary spontaneous pneumothorax: A procedure to avoid in absence of pneumothorax. A case report

INTRODUCTION

Pneumothorax is defined as accumulation of air in the pleural space with secondary lung collapse resulting in dyspnea or chest pain. Currently the optimal management of spontaneous pneumothorax has been standardized, but the question of elective surgery treatment remains unresolved in patients living in rural area with history of recurrent Primary spontaneous pneumothorax [PSP].

PRESENTATION OF CASE

A 41 years-old white man living in rural area, with a history of recurrent right spontaneous pneumothorax (three subsequent episodes) treated by positioning of chest tube, was admitted to our unit. No respiratory symptoms and normal physical exam were observed on admission although anxiety states was noted. Chest CT scan showed small apical bullae in the right upper lobe without cystic change in the pulmonary parenchyma.

DISCUSSION

Recurrence of primary spontaneous pneumothorax represents a complication most frequently occurring within the first year. Among the treatment options, surgical management is needed in 25-50% of all patients suffering from PSP, due to persistent air leak or recurrence. We report the operative complications after elective surgery in a white man living in rural area with a history of recurrent right primary spontaneous pneumothorax.

CONCLUSION

This case report highlights that elective surgery in patients living in rural area with history of recurrence PSP can lead to post-operative complications as bleeding or prolonged air leaks following the lysis of multiple pleural adhesions.

Pleurectomy versus pleural abrasion for primary spontaneous pneumothorax in children

PURPOSE

Primary spontaneous pneumothorax (PSP) represents a common indication for urgent surgical intervention in children. First episodes are often managed with thoracostomy tube, whereas recurrent episodes typically prompt surgery involving apical bleb resection and pleurodesis, either via pleurectomy or pleural abrasion. The purpose of this study was to assess whether pleurectomy or pleural abrasion was associated with lower postoperative recurrence.

METHODS

The records of patients undergoing surgery for PSP between February 2005 and December 2015 were retrospectively reviewed. Recurrence was defined as an ipsilateral pneumothorax requiring surgical intervention. Bivariate logistic regressions were used to identify factors associated with recurrence.

RESULTS

Fifty-two patients underwent 64 index operations for PSP (12 patients had surgery for contralateral pneumothorax, and each instance was analyzed separately). The mean age was 15.7±1.2years, and 79.7% (n=51) of patients were male. In addition to apical wedge resection, 53.1% (n=34) of patients underwent pleurectomy, 39.1% (n=25) underwent pleural abrasion, and 7.8% (n=5) had no pleural treatment. The overall recurrence rate was 23.4% (n=15). Recurrence was significantly lower in patients who underwent pleurectomy rather than pleural abrasion (8.8% vs. 40%, p<0.01). In patients who underwent pleural abrasion without pleurectomy, the relative risk of recurrence was 2.36 [1.41-3.92, p<0.01].

CONCLUSION

Recurrence of PSP is significantly reduced in patients undergoing pleurectomy compared to pleural abrasion.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic study.

Outcome and risk factors of recurrence after thoracoscopic bullectomy in young adults with primary spontaneous pneumothorax

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.

Surgical treatment for elderly patients with secondary spontaneous pneumothorax

OBJECTIVES

Our objective was to evaluate the validity of surgery for secondary spontaneous pneumothorax (SSP) by comparison with other treatments or with perioperative results for primary spontaneous pneumothorax (PSP).

METHODS

Between January 2009 and March 2015, 144 patients with SSP, aged 60 years or over, were treated in our institution. We reviewed the patients' characteristics, perioperative results, and relapse rate. Treatment to arrest air-leakage included surgery (n = 79), drainage only (n = 30), and pleurodesis (n = 35), and the pneumothorax relapse rate or mortality before discharge was compared for each. Additionally, we compared the perioperative results or relapse rate between SSP (n = 70) and PSP (n = 70) in patients who underwent 3-port thoracoscopic surgery.

RESULTS

There was a significant difference in the relapse rate between the surgery and non-surgery groups (5.3 vs. 27.4 %, p = 0.0006). However, no significant difference in mortality before discharge was determined (p = 0.66). Significant differences were identified between the SSP and PSP groups for operation time, duration of chest drainage, and the length of postoperative hospitalization, and the postoperative morbidity were greater in the SSP group (p < 0.0001 for all). However, there was no significant difference in postoperative 30-day mortality or the relapse rate (p = 0.5, p = 0.68, respectively).

CONCLUSIONS

Surgical treatment under general anesthesia for SSP is effective for arresting persistent air leaks or avoiding pneumothorax relapse, compared with drainage or pleurodesis, and is feasible if the appropriate perioperative management is performed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Presence of a Reticulated Trabecula-Like Structure Increases the Risk for the Recurrence of Primary Spontaneous Pneumothorax after Thoracoscopic Bullectomy

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.

Apex-to-Cupola Distance Following VATS Predicts Recurrence in Patients With Primary Spontaneous Pneumothorax

Our study sought to determine whether the size of the residual apical pleural space in young patients with primary spontaneous pneumothorax (PSP) following video-assisted thoracoscopic surgery is associated with the risk of recurrence. We retrospectively reviewed patients (≤30 years' old) with primary spontaneous pneumothorax following thoracoscopic surgery (2002-2010) in a university-affiliated hospital. The size of residual apical pleural space was estimated by measuring the apex-to-cupola distance on a postoperative chest radiograph at 2 time windows: first between postoperative day (POD) 0 and 3, and second between POD 4 and 14. A total of 149 patients were enrolled with a median follow-up of 11.2 months (interquartile range, 0.95-29.5 months), of whom 141 (94.6%) were male with a mean age of 20 years. The postoperative recurrence rate was 11.4%. Comparing the characteristics between the patients with and without recurrent pneumothorax, the patients with recurrence were younger (18.2 + 2.4 vs 20.7 + 3.7 years, P = 0.008), with a lower rate of pleurodesis (35% vs1 69%, P = 0.037), longer apex-to-cupola distance at POD 0 to 3 (22.41 ± 19.56 vs 10.07 ± 10.83 mm, P < 0.001) and POD 4 to 14 (11.82 ± 9.75 vs 5.54 ± 8.38 mm, P = 0.005) than the patients without recurrence. In a multivariate logistic regression model for recurrent pneumothorax, age <18 years (P = 0.026, odds ratio [OR]: 4.694), apex-to-cupola distance at POD 0 to 3 >10 mm (P = 0.027, OR: 5.319), and no pleurodesis during VATS (P = 0.022, OR: 5.042) were independent risk factors for recurrent pneumothorax. The recurrence rate was not low (11.4%) in young patients with PSP following VATS. Residual apical pleural space with apex-to-cupola distance of 10 mm or greater at POD 0 to 3, younger age, and no pleurodesis would increase postoperative recurrence of primary spontaneous pneumothorax.