Effects of additional pleurodesis with dextrose and talc-dextrose solution after video assisted thoracoscopic procedures for primary spontaneous pneumothorax

Joint ERS/EACTS/ESTS clinical practice guidelines on adults with spontaneous pneumothorax

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.

Joint ERS/EACTS/ESTS clinical practice guidelines on adults with spontaneous pneumothorax

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.

Pain management after pneumothorax surgery: intercostal nerve block or thoracic epidural analgesia

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.

Spontaneous pneumothorax rates following video-assisted thoracoscopic talc pleurodesis with or without resection of macroscopic bullous disease

BACKGROUND

Recurrent primary spontaneous pneumothorax (PSP) is routinely treated by video-assisted thoracoscopic (VATS) talc pleurodesis (with or without localized resection of macroscopic bullous disease). There is a paucity of published data regarding durability of the procedure and the rate of recurrent pneumothorax after such surgery, and this has significant implications from a prognostic and employment limitation perspective.

METHODS

Patients who underwent a VATS talc pleurodesis (with or without localized resection of macroscopic bullous disease) for the treatment of their second or subsequent PSP or a PSP were followed for recurrent ipsilateral pneumothorax and new contralateral PSP. Follow up was by way of telephone interview and medical record verification out to 48 months.

RESULTS

New contralateral pneumothorax occurred in 7 patients (11.1%) in the talc pleurodesis plus wedge resection group and 2 (1.8%) in the talc pleurodesis only group. There was one case of recurrent ipsilateral pneumothorax in a patient who had no inflammatory response to talc insufflation.

CONCLUSION

Video-assisted thoracoscopic (VATS) talc pleurodesis (and lung resection for macroscopic bullous disease) is a durable treatment for recurrent PSP. Patients with macroscopic disease have a significant risk of subsequent contralateral PSP.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level 4.

TYPE OF STUDY

Systematic Review of Level 1-4 studies.

Study of the Relative Frequency of Spontaneous Pneumothorax Recurrence with Two Policy Therapies: A Clinical Trial

Background

Spontaneous pneumothorax is a potentially fatal condition with a high risk of recurrence. The purpose of this study is to compare two different approaches to SP management. In the first group, patients underwent only chemical pleurodesis; in the second group, CT-scan, VATS, and then chemical pleurodesis was performed.

Materials and Methods

This study is a non-randomized clinical trial conducted on 65 patients admitted to Al-Zahra Hospital in Isfahan with a primary complaint of sudden dyspnea and a definitive diagnosis of spontaneous pneumothorax. Two studies compared the main outcomes of recurrence within six months and the time until recurrence.

Results

Age, sex, and BMI were matched between the two study groups. The side of the pneumothorax, smoking history, and pulmonary disease history did not differ significantly (P > 0.05). Pneumothorax recurrence did not differ significantly between the two groups (P: 0.477).

Conclusion

This study demonstrated no distinction between VATS and chemical pleurodesis when using only chemical pleurodesis. However, because numerous studies have suggested that one of these techniques may be beneficial for patients with SP, it is recommended to conduct additional randomized controlled trials (RCTs) with a more detailed plan and more comparable procedures, although it appears that meta-analysis design may be effective given the abundance of available RCT studies.

Efficacy of Intraoperative Hypertonic Glucose Solution Administration on Persistent Air Leak After Extended Pleurectomy/Decortication for Malignant Pleural Mesothelioma: A Retrospective Case-Control Study

Background

Persistent air leak is a common complication occurring from 6% to 23% of cases after extended pleurectomy/decortication for malignant pleural mesothelioma. Treatment options for this complication after major lung resection are well documented in literature; nevertheless, lines of evidence in extended pleurectomy/decortication for malignant pleural mesothelioma are absent. The aim of the study is to evaluate the efficacy of intraoperative administration of 50% hypertonic glucose solution in reducing duration of air leak following extended pleurectomy/decortication for malignant pleural mesothelioma.

Materials and Methods

In this retrospective case–control study, we analyzed our electronic health record and selected those patients with a histological diagnosis of malignant pleural mesothelioma who underwent extended pleurectomy/decortication in the period 2013–2021. From 2018, we introduced a lavage with 500 ml of glucose solution at 50% concentration into the chest cavity at the end of the surgical procedure. Patients operated before 2018 were used as the control group. Postoperative glycemia was measured, and patients were followed after hospital discharge until the air leak resolved and the chest tube was removed. Statistical analysis was performed using R software.

Results

A total of 71 patients met our criteria. Treatment and control groups were similar for age, sex, smoking status, number of comorbidities, tumor histotype, and side of disease. Use of hypertonic glucose solution resulted in shorter chest tube maintenance after hospital discharge (p = 0.0028). A statistically significant difference (p = 0.02) was also found in postoperative glycemia between the treatment (103 g/dl ± 8.9) and control group (98.8 g/dl ± 8.6). Days of hospitalization and chest tube maintenance during hospitalization did not significantly differ between the groups.

Interpretation

Intraoperative administration of 50% hypertonic glucose solution reduced the duration of air leak after hospital discharge. An increase in postoperative glycemia was found in the treatment group, but with no clinical effect. Hypertonic glucose solution is an effective and safe method to manage persistent air leak after extended pleurectomy/decortication for malignant pleural mesothelioma.

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

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

[Causes of resistant pleural effusions and efficiency of chemical pleurodesis in these patients]

OBJECTIVE

To study the causes of resistant pleural effusions and efficiency of chemical pleurodesis with Betadin, Iodopyrone and concentrated glucose solution in these patients.

MATERIAL AND METHODS

Resistant pleuritis with daily exudation over 300 ml lasting ≥6 days occurred in 206 (48%) out of 424 cases of pleural effusions. Twenty-seven patients underwent chemical pleurodesis with Betadine, 15 patients - mixture of Iodopyrone with concentrated glucose solution. Solutions were injected via pleural drainage.

RESULTS

In multivariate analysis, the risk factors of complicated pleuritis were air leakage, prolonged drainage period, age over 60 years, fluid output volume during thoracoscopy and higher Charlson index. Pleurodesis with a mixture of Betadine 10% 10 ml and glucose 40% 40 ml suppressed exudation in 92.6% of cases. Pleurodesis with a mixture of Iodopyron and glucose solution in the same quantities was effective in 93.4% of cases. If exudation continued, pleurodesis was repeated after 3 days. VAS score of pain syndrome following Iodopyrone injection was 3.0±1.8, in case of Betadine - 3.4±0.3. No significant hemodynamic changes were noted. In case of malignant pleural effusions and low functional parameters after fluid evacuation, favorable effect was obtained after pleurodesis with a mixture of povidone-iodine with glucose through the same catheter and subsequent removal of drainage tube.

CONCLUSION

Resistant pleural effusions with daily exudation over 300 ml for more than 6 days are characterized by advanced risk of infectious and inflammatory complications due to air leakage and duration of drainage. Pleurodesis with mixtures of Betadine or iodopyrone and 40% glucose solution is effective for resistant pleural effusions.

Mechanical or chemical and mechanical pleurodesis for spontaneous pneumothorax: what is the most effective approach in preventing recurrence? A systematic review and meta-analysis

OBJECTIVES

Surgical management of spontaneous pneumothorax typically involves wedge resection and mechanical pleurodesis. It is unclear whether combining mechanical and chemical pleurodesis can further reduce the recurrence rate. We have performed a meta-analysis of studies comparing the combined approach with mechanical pleurodesis alone.

METHODS

A comprehensive search of the existing literature was performed using PubMed, EMBASE and Web of Science for all types of studies that compared combined pleurodesis to a single approach. We used the Cochrane Risk of Bias Tool and Strengthening The Reporting of OBservational Studies in Epidemiology (STROBE) to assess the quality of the studies. Relative risk of pneumothorax recurrence was calculated, and the differences between the studies were examined. The primary outcome was the recurrence of pneumothorax.

RESULTS

Of 2301 eligible studies, 5 studies were included. Five hundred sixty-one patients who received combined pleurodesis were compared to 286 patients who received mechanical pleurodesis only. Patients treated with combined intervention had a 63% lower risk of developing a recurrent pneumothorax compared to single intervention [relative risk 0.37, 95% confidence interval (CI) 0.18-0.76; P = 0.006]. There were no statistically significant differences in the length of stay (standardized mean difference -0.17, 95% CI -0.39 to 0.05, P = 0.138), the duration of postoperative air leak (standardized mean difference 0.17, 95% CI -1.14 to 1.47, P = 0.804) or the duration of postoperative chest tube drainage (standardized mean difference -0.07, 95% CI -0.27 to 0.12, P = 0.471).

CONCLUSIONS

This meta-analysis demonstrated that combined intervention with mechanical and chemical pleurodesis for spontaneous pneumothorax may be more effective in preventing recurrence than mechanical pleurodesis alone. These findings will provide some guidance to surgeons in the decision-making process.

Mechanical versus Chemical Pleurodesis after Bullectomy for Primary Spontaneous Pneumothorax: A Systemic Review and Meta-Analysis

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.

Efficacy of treatments in primary spontaneous pneumothorax: A systematic review and network meta-analysis of randomized clinical trials

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.

Pleural Coating by 50% Glucose Solution Reduces Postoperative Recurrence of Spontaneous Pneumothorax

BACKGROUND

Video-assisted thoracoscopic surgery is the standard procedure for treatment of spontaneous pneumothorax. However, postoperative recurrence is relatively common even if an absorbable covering sheet is used for reinforcement of the visceral pleura. Injection of a high concentration glucose solution to the thoracic cavity was recently reported to be effective in stopping postoperative air leakage or as a prophylactic procedure to prevent postoperative recurrence of spontaneous pneumothorax. Therefore, we used 50 mL of a 50% glucose solution for pleural coating (GPC) on an absorbable sheet intraoperatively to prevent postoperative recurrence of spontaneous pneumothorax. This is a retrospective study, and patient backgrounds are heterogeneous. We evaluated the feasibility of GPC using propensity scores to adjust for heterogeneity in their backgrounds.

METHODS

Between January 2010 and December 2017, 376 patients who underwent video-assisted thoracoscopic surgery, with or without GPC, were evaluated. The GPC group consisted of 106 patients, and the non-GPC group consisted of 270. We analyzed the factors preventing postoperative recurrence of spontaneous pneumothorax by univariate analysis and Cox regression analysis with or without propensity score matching.

RESULTS

Univariate analysis revealed age of 25 or older, smoking habit, no history of an ipsilateral operation, and GPC were significant factors preventing postoperative recurrence. GPC significantly prevented postoperative recurrence as shown by Cox regression analysis with propensity score matching (hazard ratio, 0.15; p = 0.014) and the inverse-probability of treatment weighted method (hazard ratio, 0.23; p = 0.0038).

CONCLUSIONS

Intraoperative GPC significantly reduced the postoperative recurrence rate of spontaneous pneumothorax.

Effectiveness of chemical pleurodesis in spontaneous pneumothorax recurrence prevention: a systematic review

Objectives

Spontaneous pneumothorax is a common pathology. International guidelines suggest pleurodesis for non-resolving air leak or recurrence prevention at second occurrence. This study comprehensively reviews the existing literature regarding chemical pleurodesis efficacy.

Design

We systematically reviewed the literature to identify relevant randomised controlled trials (RCTs), case–control studies and case series. We described the findings of these studies and tabulated relative recurrence rates or ORs (in studies with control groups). Meta-analysis was not performed due to substantial clinical heterogeneity.

Results

Of 560 abstracts identified by our search strategy, 50 were included in our systematic review following screening. Recurrence rates in patients with chest tube drainage only were between 26.1% and 50.1%. Thoracoscopic talc poudrage (four studies (n=249)) provided recurrence rates of between 2.5% and 10.2% with the only RCT suggesting an OR of 0.10 compared with drainage alone. In comparison, talc administration during video-assisted thoracic surgery (VATS) from eight studies (n=2324) recurrence was between 0.0% and 3.2%, but the RCT did not demonstrate a significant difference compared with bleb/bullectomy alone. Minocycline appears similarly effective post-VATS (recurrence rates 0.0–2.9%). Prolonged air leak and recurrence prevention using tetracycline via chest drain (n=726) is likely to provide recurrence rates between 13.0% and 33.3% and autologous blood patch pleurodesis (n=270) between 15.6% and 18.2%.

Conclusions

Chemical pleurodesis postsurgical treatment or via thoracoscopy appears to be most effective. Evidence for definitive success rates of each agent is limited by the small number of randomised trials or other comparative studies.

Mechanical pleurodesis does not reduce recurrence of spontaneous pneumothorax: a randomized trial

BACKGROUND

Mechanical pleurodesis is widely used to treat primary spontaneous pneumothorax to decrease postoperative recurrence after thoracoscopic bullectomy, but it is unclear whether it actually reduces primary spontaneous pneumothorax recurrence. We aimed to investigate the effectiveness of mechanical pleurodesis after thoracoscopic treatment of primary spontaneous pneumothorax.

METHODS

In our parallel-group, prospective, randomized, controlled trail at 2 hospitals in China, 289 patients were enrolled from January 2010 to January 2013. Patients were randomly assigned (1:1) to receive thoracoscopic wedge resection only (WR group) or thoracoscopic wedge resection and mechanical pleurodesis (WR+MP group). This trial is registered with ClinicalTrial.gov (NCT01463553).

RESULTS

Intraoperative bleeding and postoperative pleural drainage were significantly lower in the thoracoscopic WR only group. Postoperative recurrence rate did not significantly differ between groups (log-rank test p=0.791; Breslow test p=0.722). In the thoracoscopic WR only group, no recurrences were found when bullae were isolated or limited; recurrence was 7.5% with the presence of multiple bullae. Younger patients had an increased risk of recurrence (relative risk 3.015; 95% confidence interval 1.092 to 8.324).

CONCLUSIONS

Thoracoscopic mechanical pleurodesis did not significantly decrease primary spontaneous pneumothorax recurrence compared with simple wedge resection, but intraoperative bleeding and postoperative pleural drainage rates were higher. Younger age increases the risk of recurrence.