Recurrence of primary spontaneous pneumothorax in young adults and children

Non-stapling thoracoscopic surgery for spontaneous pneumothorax in young patients

OBJECTIVES

Spontaneous pneumothorax in young patients has a high recurrence rate, even after surgical treatment, and bulla neogenesis around stapled lesions has been reported as a cause of postoperative recurrence. We investigate the clinical safety and long-term outcome of non-stapling thoracoscopic surgery for spontaneous pneumothorax in young patients.

METHODS

Twenty-seven non-stapling thoracoscopic surgeries for pneumothorax in 24 patients younger than 25 years were retrospectively reviewed. The non-stapling surgical techniques used to treat bullae included thoracoscopic suture plication, soft-coagulation, covering, and ligation. Long-term follow-up was conducted by telephone or by a mailed questionnaire.

RESULTS

In 22 (81.5%) operations, suture plication, soft-coagulation, and covering procedures were used in combination. The median number of bullae treated in one operation was 2 (range, 0-6). The median operative time was 97 min, and the median postoperative drainage and postoperative hospital stay periods were 1 and 3 days, respectively. No complications of grade 2 or higher were observed. Patients were followed for at least 30 (median, 37) months. The postoperative recurrence rate was 3.7%, with one case of recurrence due to bulla neogenesis at a distant site.

CONCLUSION

Non-stapling thoracoscopic surgery with covering procedure for pneumothorax in young patients might reduce postoperative recurrence.

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.

Trends in recurrence of primary spontaneous pneumothorax in young population after treatment for first episode based on a nationwide population data

The aim of this study is to identifying post treatment recurrence rates in pneumothorax patients under 35 and without any comorbidities according to the treatment types, gender, and age categories based on nationwide population data. Clinical information of pneumothorax patients was extracted from the Korean National Health Insurance Service (NHIS) database between January 2002 and December 2020. Enrolled patients were categorized into two groups; (1) Group I, those who underwent conservative management including pain relief, oxygen therapy, and closed thoracostomy, and (2) Group II, surgical intervention. Recurrence rates were compared according to age, gender, and type of treatment. Surgical intervention was performed in 25.6% patients as first treatment. The overall recurrence rate was 20.3%. Male patients showed a higher 5-year recurrence rate than female (20.8% vs. 10.9%, p < 0.001). Those with conservative management showed lower 5-year recurrence rates than those with surgical treatment (7.9% vs. 23.7%, p < 0.001). The 5-year recurrence rates of patients aged 14≤, and < 20 was higher than other age groups (29.2% vs. 4.5 and 11.9%, p < 0.001). Surgical intervention, male gender and aged under 20 showed association with higher recurrence rates.

Management of primary spontaneous pneumothorax in children: A single institution protocol analysis

BACKGROUND

The Midwest Pediatric Surgery Consortium (MWPSC) suggested a simple aspiration of primary spontaneous pneumothorax (PSP) protocol, failing which, Video-Assisted Thoracoscopic Surgery (VATS) should be considered. We describe our outcomes using this suggested protocol.

METHODS

A single institution retrospective analysis was conducted on patients between 12 and 18 years who were diagnosed with PSP from 2016 to 2021. Initial management involved aspiration alone with a ≤12 F percutaneous thoracostomy tube followed by clamping of the tube and chest radiograph at 6 h. Success was defined as ≤2 cm distance between chest wall and lung at the apex and no air leak when the clamp was released. VATS followed if aspiration failed.

RESULTS

Fifty-nine patients were included. Median age was 16.8 years (IQR 15.9, 17.3). Aspiration was successful in 33% (20), while 66% (39) required VATS. The median LOS with successful aspiration was 20.4 h (IQR 16.8, 34.8), while median LOS after VATS was 3.1 days (IQR 2.6, 4). In comparison, in the MWPSC study, the mean LOS for those managed with a chest tube after failed aspiration was 6.0 days (±5.5). Recurrence after successful aspiration was 45% (n = 9), while recurrence after VATS was 25% (n = 10). Median time to recurrence after successful aspiration was sooner than that of the VATS group [16.6 days (IQR 5.4, 19.2) vs. 389.5 days (IQR 94.1, 907.0) p = 0.01].

CONCLUSION

Simple aspiration is safe and effective initial management for children with PSP, although most will require VATS. However, early VATS reduces length of stay and morbidity.

LEVEL OF EVIDENCE

IV. Retrospective study.

Early risk factors of operative management for hospitalization children with spontaneous pneumothorax

BACKGROUND

The optimal timing of operative management in children with primary spontaneous pneumothorax (PSP) remains controversial. This study sought to determine early risk factors for failure of chest tube nonoperative management during the initial hospitalization in adolescents with PSP.

METHODS

A retrospective review was conducted for children (aged ≤18 years) admitted to a single tertiary care referral center for their first presentation of a PSP managed with at least 48 h of chest tube decompression (CTD) alone. Patient outcomes and early risk factors for operative management were analyzed by multivariate regression.

RESULTS

Of the 39 patients who met inclusion criteria, 15 (38.5%) patients failed nonoperative treatment while 24 (61.5%) patients were managed with CTD therapy alone. Progression to thoracoscopic surgery was associated with longer CTD of 8 vs 3 days and hospital length of stay of 9 vs 4 days when compared to nonoperative management (p < 0.001, both). Air leak and increase in pneumothorax size at 24 h after CTD were independently associated with progression to surgery (p = 0.007, p = 0.002). Combined, these risk factors were associated with a significant increase in recurrence (OR 6.00, 95% CI 1.11-41.11, p = 0.048). There were no significant differences between PSP management strategies regarding cumulative radiation exposure or 2 year recurrence.

CONCLUSIONS

Air leak or increasing pneumothorax size within 24 h of CTD are highly correlated with failed nonoperative management during the initial hospitalization in pediatric patients with PSP. This data may be useful in the development of pediatric-specific treatment algorithms to optimally manage these patients.

LEVEL OF EVIDENCE

Treatment study, Level III.

Nonintubated versus intubated thoracoscopic bullectomy for primary spontaneous pneumothorax: A multicenter propensity-matched analysis

BACKGROUND

We aimed at comparing in a multicenter propensity-matched analysis, results of nonintubated versus intubated video-assisted thoracic surgery (VATS) bullectomy/blebectomy for primary spontaneous pneumothorax (PSP).

METHODS

Eleven Institutions participated in the study. A total of 208 patients underwent VATS bullectomy by intubated (IVATS) (N = 138) or nonintubated (NIVATS) (N = 70) anesthesia during 60 months. After propensity matching, 70 pairs of patients were compared. Anesthesia in NIVATS included intercostal (N = 61), paravertebral (N = 5) or thoracic epidural (N = 4) block and sedation with (N = 24) or without (N = 46) laryngeal mask under spontaneous ventilation. In the IVATS group, all patients underwent double-lumen-intubation and mechanical ventilation. Primary outcomes were morbidity and recurrence rates.

RESULTS

There was no difference in age (26.7 ± 8 vs 27.4 ± 9 years), body mass index (19.7 ± 2.6 vs 20.6 ± 2.5), and American Society of Anesthesiology score (2 vs 2). Main results show no difference both in morbidity (11.4% vs 12.8%; p = 0.79) and recurrence free rates (92.3% vs 91.4%; p = 0.49) between NIVATS and IVATS, respectively, whereas a difference favoring the NIVATS group was found in anesthesia time (p < 0.0001) and operative time (p < 0.0001), drainage time (p = 0.001), and hospital stay (p < 0.0001). There was no conversion to thoracotomy and no hospital mortality. One patient in the NIVATS group needed reoperation due to chest wall bleeding.

CONCLUSION

Results of this multicenter propensity-matched study have shown no intergroup difference in morbidity and recurrence rates whereas shorter operation room time and hospital stay favored the NIVATS group, suggesting a potential increase in the role of NIVATS in surgical management of PSP. Further prospective studies are warranted.

Management of primary spontaneous pneumothorax in teenagers: An 11-year study

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.

Children with large primary spontaneous pneumothoraxes may benefit from early operative intervention

PURPOSE

The initial management of primary spontaneous pneumothoraxes (PSP) in children remains controversial, particularly regarding the timing of operative intervention. This study aimed to identify factors associated with failure of non-operative management of PSP.

METHODS

A single-center, retrospective review was performed for patients presenting with PSP. Demographics and clinical predictors were collected. Patients successfully managed non-operatively were compared to failed non-operative management. Fischer exact and Mann-Whitney tests were used as appropriate.

RESULTS

Fifty-seven pediatric patients were identified as having PSP. Four patients underwent initial surgical intervention, 60% (n = 34) were successfully managed non-operatively, while 33% (n = 19) failed non-operative management and underwent video-assisted thoracic surgery (VATS). Those who failed were more likely to have PSP > 2 cm on initial X-ray (79% vs. 44%, p = 0.021) and have a persistent air leak for > 48 h (47% vs 6%, p ≤ 0.001). LOS was greater in the failure group (11.5 ± 5.1 vs 3.1 ± 2.5, p ≤ 0.001) as well as higher complication rates (21% vs 0%, p = 0.013).

CONCLUSION

Our findings suggest that patients presenting with PSP of > 2 cm or have a persistent air leak for > 48 h despite chest tube management are unlikely to be treated by chest tube alone and may benefit from earlier operative intervention.

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.

Simultaneous Viscum pleurodesis and video-assisted thoracic surgery (VATS) bullectomy in patients with primary spontaneous pneumothorax

Although surgery is the gold standard for treatment of primary spontaneous pneumothorax (PSP), recurrence after surgery remains a concern. This study sought to evaluate the efficacy of simultaneous pleurodesis using Viscum album (VA) extract and video-assisted thoracic surgery (VATS) bullectomy for the treatment of PSP. From March 2016 to June 2020, 175 patients with PSP underwent bullectomy and intraoperative pleurodesis with VA extract at a single institution. All operations were performed through thoracoscopy by one surgeon. Upon completion of bullectomy, a polyglycolic acid sheet was used to cover the stapler lines, and 40 mg of VA extract was instilled over the entire chest wall before chest tube placement. The median operating time was 20 min (interquartile ranges, 15–30) and the median indwelling time of chest drainage was 2 days (interquartile ranges, 2–3). There were no postoperative complications over grade 3. During the median follow-up period of 38 months (interquartile ranges, 15–48), no recurrence of pneumothorax was observed. The results of this study demonstrated that simultaneous Viscum pleurodesis and VATS bullectomy provides a feasible and effective treatment option for preventing postoperative pneumothorax in patients with PSP.

Feasibility of application of an absorbable topical collagen hemostat sheet (INTEGRAN®) for prevention of postoperative recurrence of pneumothorax in youths

Background

Staple-line coverage is an effective method for prevention of postoperative recurrence of pneumothorax. However, the recurrence rate in young patients is still unsatisfactory using this method. Moreover, there is no consensus about the optimal material for use in this technique. To explore new material for this technique, we conducted this study to evaluate the safety of an absorbable topical collagen hemostat (INTEGRAN^®) for staple-line coverage in pneumothorax surgery in young patients.

Methods

A single-arm prospective interventional study was performed in 25 patients (age <25 years old) with primary spontaneous pneumothorax (PSP) who underwent wedge resection with staple-line coverage with INTEGRAN^® between 2017 and 2020. The rate of material-related adverse events (defined as a body temperature ≥38 ℃ continuing for ≥2 days, postoperative WBC >18,000/mm³ and/or CRP >15 mg/dL, or acute empyema within 30 postoperative days) was defined as the primary endpoint. The 1-year postoperative rates of recurrence and of new bullae around the staple-line were also measured.

Results

The median age was 19 years old. None of the patients had a body temperature ≥38 ℃ continuing for ≥2 days, extra-abnormal examination data, and acute empyema findings. At 1-year postoperatively, the recurrence rate was 12.0%, and the rate of new bullae around the staple-line was 16.7%.

Conclusions

This study showed the safety of use of INTEGRAN^® for staple-line coverage in pneumothorax surgery in young adults. The short-term recurrence rate was acceptable given the high-risk cohort examined in the study. A prospective randomized controlled study is needed for evaluation of the efficacy of INTEGRAN^® for prevention of recurrence of PSP.

Trial Registration

UMIN000026530 at UMIN Clinical Trials Registry

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.

An evidence-based review of primary spontaneous pneumothorax in the adolescent population

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Primary spontaneous pneumothorax in children: A single institutional experience

BACKGROUND

The treatment of primary spontaneous pneumothorax (PSP) remains controversial. We aimed to examine the role of chest computed tomography (CT), the advantages of pigtail catheter versus chest tube regarding duration of drainage or hospitalization period, and the impact of small PSP and surgical treatment on recurrence rate.

METHODS

We retrospectively reviewed the medical records of 109 children with PSP (20 years' period). Patients with recurrent and those with non-recurrent PSP were compared.

RESULTS

We recorded 183 episodes of PSP (45% recurrences), 89 patients (97%) were male, and the median age at presentation was 16 years. There were no significant differences between recurrence and non-recurrence PSP regarding age, gender, medical background, presentation symptoms, type of chest drain, median hospitalization length and median follow-up period. Recurrences were less frequent among patients who presented with small PSP and were treated conservatively (P = 0.029). PSP was almost always unilateral and the recurrence was observed ipsilateral in almost 80% of the cases. CT was more frequently used and blebs/bullae were more frequently found among patients with recurrent PSP. Pigtail use had no advantage in reducing hospitalization period and surgical procedures prevented recurrences.

CONCLUSION

The size of pneumothorax at presentation helps to predict recurrences. There are no differences regarding duration of drainage or hospitalization period in the use of pigtail compared to chest tube. CT helps evaluate findings in the lungs in recurrent cases of PSP and surgery prevents recurrences effectively.

Should We Consider the Resected Lung Volume in Primary Spontaneous Pneumothorax?

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.

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 rate and risk factors for recurrence after thoracoscopic surgery for primary spontaneous pneumothorax: A nationwide population-based study

PURPOSE

This large-scale nationwide population-based study aimed to determine the recurrence rate and risk factors for recurrence after video-assisted thoracoscopic surgery (VATS) for primary spontaneous pneumothorax (PSP).

METHODS

This retrospective study used data from the Taiwan National Health Insurance Database to identify individuals who underwent VATS for PSP from 2007 to 2014. All patients were followed up until December 31, 2017. Study variables included demographic characteristics, intensive care unit admission, lung resection status, use of non-steroidal anti-inflammatory drugs (NSAIDs), and hospital level. The primary outcome was 1-year recurrence, and the secondary outcomes were the 1-year rate of reintervention for recurrence and overall recurrence rate.

RESULTS

During the study period, 6654 patients underwent VATS for PSP (average age: 23.2 years, 89.1% male), including 910 patients (13.7%) who experienced recurrence within 1 year and 531 patients (8.0%) who required reintervention within 1 year. The overall recurrence rate was 24.8%, with an average follow-up time of 6.7 years. Age ≤18 years and the use of NSAIDs, especially ketorolac, were significant risk factors for 1-year recurrence and overall recurrence. Younger age was a risk factor for 1-year reintervention. In subgroup analysis, NSAID use was a significant risk factor for 1-year recurrence, 1-year reintervention, and overall recurrence in pediatric patients but not in adult patients.

CONCLUSIONS

In Taiwan, the 1-year recurrence rate was 13.7% after VATS for PSP. Younger age and the use of NSAIDs, especially ketorolac, were significant risk factors for short- and long-term recurrence after VATS for PSP.

Is conventional management of primary spontaneous pneumothorax appropriate?

OBJECTIVE

This study aimed to evaluate the recurrence rate after primary and secondary conservative treatments and to clarify the validity of current primary spontaneous pneumothorax management by comparing secondary conservative treatment and surgical outcomes.

METHODS

Data from 166 patients with primary spontaneous pneumothorax treated at a single site between September 2015 and March 2019 were retrospectively evaluated. Patient characteristics of those who received primary conservative therapy (n = 166) and secondary conservative therapy (n = 28) were summarized. The outcomes from patients who experienced recurrence (n = 64) were compared based on those who underwent surgery (n = 24) and those who underwent secondary conservative therapy (n = 28).

RESULTS

The post-treatment day 60 recurrence rate was 27.1 and 49.5% cases in the primary and secondary treatment groups, respectively, which was significantly higher after secondary treatment than after primary treatment with conservative therapy (p = 0.032). The post-treatment one-year recurrence rate was 13.5 and 57.9% in patients who underwent surgery and secondary conservative treatment, respectively; secondary conservative treatment resulted in a significantly higher recurrence rate than surgery (p < 0.001).

CONCLUSIONS

There is evidence for guidelines that recommend surgery for recurrent primary spontaneous pneumothorax after primary conservative therapy based on its lower and more delayed post-treatment recurrence rate than secondary treatment with conservative therapy.

Risk factors of postoperative recurrence of primary spontaneous pneumothorax

Background

Spontaneous pneumothorax is common in relatively young, healthy patients. The risk factors for postoperative recurrence after correction are not fully understood.

Methods

We retrospectively reviewed the records of patients who underwent surgery for spontaneous pneumothorax between January 2006 and October 2017. We assessed the possible factors causing postoperative recurrence using univariate and multivariate analyses. We then used the inverse probability of treatment-weighted method to correct for confounding factors.

Results

Postoperative recurrence was observed in 41 of 233 patients (17.6%). A significant association with recurrence was noted for primary spontaneous pneumothorax (PSP), never smokers, thoracoscopic surgery, patients younger than 30 years, operative time less than 100 minutes, and surgery by a resident surgeon. Patients younger than 30 years of age had a 5-year recurrence-free probability of 46.3%. On multivariate analysis, patients younger than 30 years was an independent risk factor for recurrence. The confounding factors for recurrence of PSP included patients younger than 30 years, surgery by a resident surgeon, and thoracoscopic surgery. After adjusting for confounders, patients younger than 30 years was the only factor associated with recurrence (P=0.015). Patients who underwent bulla ligation with pleural reinforcement using an absorbable polyglycolic acid (PGA) sheet had a 4% recurrence rate and a 5-year recurrence-free probability of 90.0%.

Conclusions

Patients younger than 30 years of age is a significant factor for postoperative recurrence in patients with PSP. Surgeons may attempt to prevent postoperative recurrence by devising the operative method and pleural reinforcement methods.

Does a gender have something to do with clinical pictures of primary spontaneous pneumothorax?

OBJECTIVE

Primary spontaneous pneumothorax is relatively rarer in women than in men. In addition, women develop secondary spontaneous pneumothorax, such as lymphangioleiomyomatosis, which is rare and difficult to diagnose. Therefore, the clinical characteristics of primary spontaneous pneumothorax in women remain unknown presently. We compared the clinical characteristics of primary spontaneous pneumothorax between the two sexes at two pneumothorax centers.

METHODS

Between January 2015 and July 2019, we retrospectively evaluated 627 cases (106 women and 521 men) who underwent first video-assisted thoracoscopic surgery for primary spontaneous pneumothorax and extracted the medical backgrounds and postoperative recurrence between the sexes. Univariate and multivariate analysis was used to examine the effect of sexual specificity on postoperative recurrence.

RESULTS

Among women and men with PSP, the mean ages were 27.8 ± 10.7 and 24.3 ± 10.0 years, respectively; their mean heights were 162.0 ± 5.9 and 173.3 ± 6.1 cm, respectively. These differences were statistically significant. Three women (2.8%) and 54 men (10.4%) developed postoperative recurrence, which showed significant difference on Kaplan-Meier analysis (p = 0.027). Univariate and multivariate analysis showed the factors; women (p = 0.045, hazard ratio: 0.289 [95% confidence interval 0.086-0.973]) and smoker (p = 0.035, hazard ratio: 0.269 [95% confidence interval 0.079-0.909]) had the preventing factor for postoperative recurrence, respectively.

CONCLUSIONS

Women with PSP had lower postoperative recurrence rate than men. Although we could not reveal why women had lower postoperative recurrence rates than men in this study, the sexual difference such as hormonal cycle, development of body structure possibly affects the clinical characteristics of women with primary spontaneous pneumothorax.

Use of imaging studies to predict postoperative recurrences of primary spontaneous pneumothorax

Background

Bullectomy with pleural procedure is the most effective means of treating primary spontaneous pneumothorax (PSP). However, recurrences after thoracoscopic bullectomy are unexpectedly frequent. Our aim was to identify the premonitory imaging features after thoracoscopic bullectomy that may associate with recurrences in PSP.

Methods

The medical records of all patients undergoing thoracoscopic bullectomy for PSP between January 2013 and September 2016 were subject to review. A total of 154 procedures performed on 147 patients qualified for study. Clinical outcomes and characteristics of patients were reviewed and serial chest radiographies were assessed, analyzing risk factors for postoperative recurrences.

Results

Median age of the male-predominant cohort (93.5%) was 19 (range, 15–39) years. Median operative time was 35 min, none reflecting complications. Postoperatively, diaphragmatic tenting was identified in 78 patients (50.6%), and pleural residual cavity was identified by chest radiography in 102 (66.2%). After discharge, remained diaphragmatic tenting (38/154, 24.7%) and pleural residual cavity (52/154, 33.8%) were identified by chest radiography. In univariate analysis, remained diaphragmatic tenting (P=0.026) and length of pleural residual cavity (P=0.024) emerged as risk factors for recurrence; and both reached significance in multivariate analysis (P=0.020 and P=0.018, respectively).

Conclusions

Remained diaphragmatic tenting after thoracoscopic surgery for PSP may be associated with the risk of postoperative recurrence.

Clinicopathological significance of staple line coverage with an oxidized regenerated cellulose sheet after bullectomy for primary spontaneous pneumothorax

BACKGROUND

Oxidized regenerated cellulose (ORC) sheet, in surgery of primary spontaneous pneumothorax, is used to reinforce the visceral pleura around the staple line coverage aiming to prevent a postoperative recurrence. We evaluated the effect of ORC on recurrence within 2 years after surgery.

METHODS

A total of 201 patients aged < 40 years who underwent bullectomy for primary spontaneous pneumothorax at our institution were retrospectively reviewed. They were classified into an ORC sheet coverage group (ORC group, n = 100) and a non-coverage group (n-ORC group, n = 101). Two-year recurrence-free survival rates are assessed between the two groups with associated analysis of radiographical and operative findings.

RESULTS

ORC had no effect on the recurrence rate. CT images and re-operative findings showed regenerated bullae in 19 and 14 patients, close to staple lines in 14 and 11 patients, respectively. White pleural thickening within the covered area was observed in all patients of the ORC group. Pathological findings also showed pleural thickening in eight patients and bulla regeneration under pleural thickening in six patients.

CONCLUSIONS

Coverage with an ORC sheet after bullectomy did not prevent the regeneration of bullae and postoperative recurrence, regardless of exerting a reinforcement effect on the visceral pleura histologically.

Management of the Pediatric Spontaneous Pneumothorax: The Role of Video-Assisted Thoracoscopic Surgery

Purpose: Treatment of pneumothorax involves conservative treatment and surgery. The aim of this study was to assess the best approach of initial treatment and long-term outcomes of video-assisted thoracic surgery (VATS) for primary spontaneous pneumothorax in pediatric patients. Patients and Methods: From January 2009 until June 2019, 36 patients younger than the age of 18 who were treated for spontaneous pneumothorax were included into retrospective study. Patients were divided into 2 groups, non-VATS and VATS, depending on the way they were treated. The groups were compared regarding demographic and clinical data and outcomes of treatment (the length of hospitalization, the frequency of postoperative complications, and reoperations). Results: Out of 36 patients, there were 24 boys and 12 girls with median age of 16.5 years. Median duration of hospitalization was 8 days. Eight patients were treated by observation and 28 by chest tube insertion. In 14 patients with spontaneous pneumothorax, VATS was performed [indications were persistent air leak in 8 (57%) and recurrent pneumothorax in 6 (43%) children]. Patients who underwent surgery had significantly higher length of hospitalization (P < .001) and lower rate of recurrences (P = .003) than those who did not. In 12 (86%) patients, blebs were found intraoperative, and in all of them, pleurodesis was performed. Duration of chest tube insertion was significantly longer in patients who experienced recurrent pneumothorax (P < .001). Conclusions: VATS is successful, efficient, and safe method of treatment for spontaneous pneumothorax, due to its significantly lower rate of recurrence in comparison with chest tube insertion.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

III.

Contralateral bulla neogenesis associated with postoperative recurrences of primary spontaneous pneumothorax in young patients

Background

Video-assisted thoracoscopic surgery (VATS) is considered an acceptable treatment for recurrent primary spontaneous pneumothorax (PSP). However, recent reports have described a high postoperative recurrence rate in young patients with PSP. We hypothesized that ineffective VATS may have been performed for these patients (aged <25 years). We evaluated the factors preventing postoperative recurrence in young PSP patients in order to identify patients with effective surgery.

Methods

Between April 2009 and December 2018, we retrospectively evaluated 92 patients aged <25 years who underwent first VATS bullectomy for PSP. Factors such as gender, smoking habit, history of contralateral PSP, family history, body mass index (BMI), and contralateral bulla neogenesis on high-resolution computed tomography were evaluated.

Results

The mean BMI was 18.8±1.8. Contralateral bulla neogenesis was present in 31 patients (33.7%). The median period of observation for postoperative recurrence was 401.5 days. Thirty cases (32.6%) developed postoperative recurrence. Univariate and multivariable analyses showed that a BMI ≥18.0 and no contralateral bulla neogenesis were significant factors preventing postoperative recurrence (P=0.018, hazard ratio: 0.41 and P=0.0046, hazard ratio: 0.25, respectively).

Conclusions

Although the patients aged <25 years have a high rate of postoperative recurrence, the patients with BMI ≥18.0 and no contralateral bulla neogenesis have a significantly lower rate of postoperative recurrence rate.

Do Blebs or Bullae on High-Resolution Computed Tomography Predict Ipsilateral Recurrence in Young Patients at the First Episode of Primary Spontaneous Pneumothorax?

Background

The relationship between the size of bullae and pneumothorax recurrence is controversial. The aim of this study was to retrospectively evaluate the role of blebs or bullae in predicting ipsilateral recurrence in young patients experiencing their first episode of primary spontaneous pneumothorax (PSP) who underwent conservative treatment.

Methods

A total of 299 cases of first-episode PSP were analyzed. The status of blebs or bullae was reviewed on high-resolution computed tomography (HRCT). The dystrophic severity score (DSS; range, 0 to 6 points) was calculated based on HRCT.

Results

The 5-year recurrence rate was 38.2%. In univariate analysis, age (<20 years), body mass index (<20 kg/m²), a unilateral lesion, and intermediate risk (DSS 4 and 5) were associated with recurrence. Sex; smoking history; and the presence, number, and maximal size of blebs or bullae were not related to recurrence. In Cox regression, age and intermediate risk were independent risk factors for recurrence. High risk (DDS 6) was not an independent risk factor.

Conclusion

The presence, number, and size of blebs or bullae did not affect ipsilateral recurrence. DSS failed to show a positive correlation between severity and recurrence. The decision to perform surgery in patients experiencing their first episode of PSP should not be determined by the severity of blebs and bullae.

The influence of pleurodesis on the outcome of primary spontaneous pneumothorax in children

BACKGROUND

Primary spontaneous pneumothorax (PSP) has a high rate of recurrence, and pleurodesis has been shown to decrease the rate of recurrence in adult PSP. For pediatric PSP patients, there are only a few case series available and evidence on the benefits of pleurodesis is insufficient. This study aimed to analyze the outcome of pleurodesis among pediatric PSP patients via a nationwide population-based cohort in Taiwan.

METHODS

The hospitalization data from the pediatric intensive care sampling file of the National Health Insurance Research Database from January 1 to December 31, 2010, were retrieved and analyzed. Children aged 0-18 years with a discharge diagnosis of PSP (ICD-9: 512, 512.0, and 512.8) were enrolled in the study. Demographic data, management strategies, and clinical outcomes were recorded and analyzed as well.

RESULTS

A total of 1005 hospitalization cases were identified and divided into the pleurodesis (409 hospitalizations) and nonpleurodesis (596 hospitalizations) groups. In the univariate analysis, thoracoscopic surgery for PSP decreased the incidence of recurrence (hazard ratio [HR], 0.46; 95% CI, 0.32-0.67) and the need for further surgical intervention (HR, 0.29; 95% CI, 0.18-0.47); however, conventional open surgery did not. A lesser incidence of PSP recurrence (HR, 0.53; 95% CI, 0.37-0.78) and fewer subsequent surgical interventions (HR, 0.32; 95% CI, 0.20-0.52) were found in the pleurodesis group in comparison with the nonpleurodesis group. A multivariate Cox regression analysis revealed that pleurodesis was the only significant factor capable of decreasing the incidence of PSP recurrence (HR, 0.57; 95% CI, 0.38-0.86) and the need for further surgical intervention (HR, 0.40; 95% CI, 0.23-0.69).

CONCLUSION

Pleurodesis reduces the rate of recurrence and the need for further surgical intervention in pediatric PSP. It may be considered as the method of choice for the management of PSP in children.

Management and recurrence of spontaneous pneumothorax in children

Objective

No guideline clearly prescribes an approach to management of spontaneous pneumothorax in children. The objectives of this study were to evaluate practice variation in the management of spontaneous pneumothorax in children and its probability of recurrence.

Methods

This study was a retrospective chart review followed by a phone follow-up that included all children who had visited a tertiary care paediatric hospital for a first episode of spontaneous pneumothorax between 2008 and 2017. The primary outcomes were the management of pneumothorax (observation, oxygen, needle aspiration, intercostal chest tube, surgery) and the probability of recurrence. All charts were evaluated by a rater using a standardized report form and 10% of the charts were evaluated in duplicate. All children/families were contacted by phone to assess recurrence. The primary analyses were the proportions of each treatment modalities and recurrence, respectively.

Results

During the study period, 76 children were deemed eligible for the study. Among them, 59 had a primary spontaneous pneumothorax while 17 were secondary. The most common first therapeutic approaches were chest tube insertion (31), oxygen alone (27), and observation (14). A total of 54 patients were available for follow-up among whom a recurrence was observed in 28 (37% of the total cohort or 52% of available children).

Conclusion

Chest tube insertion was the first line of treatment in about 40% of children with a first spontaneous pneumothorax. In this population, the recurrence probability is established between 37 and 52% and the majority occurs in the following months.

Neo-generation of neogenetic bullae after surgery for spontaneous pneumothorax in young adults: a prospective study

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.

Current Practice in the Management of Spontaneous Pneumothorax in Children

INTRODUCTION

There is a lack of pediatric-specific guidelines for the workup and management of primary spontaneous pneumothorax (PSP) in children. The aim of this study was to describe current practices among North American pediatric surgeons.

MATERIALS AND METHODS

An online survey comprising 18 questions was sent out through the American Pediatric Surgical Association Outcomes and Clinical Trials Committee to all members. Bivariate analysis was performed using Chi-square analysis.

RESULTS

A total of 287 surveys were completed (33% response rate). For a first episode of PSP, 57% of surgeons opt for chest tube drainage, 4% for upfront video-assisted thoracoscopic surgery (VATS), 3% for needle aspiration, and 29% for only oxygen administration. Eighty-one percent of surgeons report that the size of the pneumothorax influences management. However, neither practice setting (P = .87) nor years in practice (P = .11) correlated with initial management strategy. For patients with a persistent air leak after chest tube placement, there is wide variation in duration of observation before performing VATS, with 40% operating after 3 days, but 21% waiting at least 5 days. The use of chest computed tomography (CT) is also highly variable. Eighty-two percent of respondents perform surgery only after the second episode of PSP. Most perform a stapled apical blebectomy and mechanical pleurodesis for both initial and recurrent PSP.

CONCLUSION

There is significant variation among pediatric surgeons in the management of spontaneous pneumothorax, including the use of CT, timing of operation, and duration of observation for air leak before performing surgery. Prospective data are needed to better inform guidelines and standardize practice.

Optimal timing of video-assisted thoracoscopic surgery for primary spontaneous pneumothorax in children

PURPOSE

There is no consensus in the pediatric surgical community about when to recommend video-assisted thoracoscopic surgery (VATS) for patients with primary spontaneous pneumothorax (PSP). We aimed to identify factors that predict the likelihood of requiring VATS, and to compare recurrence rates and healthcare utilization among different management approaches to PSP.

METHODS

A retrospective chart review and a telephone survey were conducted on all patients 12-21years who were diagnosed with PSP from 2007 to 2015. Data were extracted on patient demographics, initial management, hospital length of stay (LOS), and subsequent admissions, procedures, and recurrences.

RESULTS

A total of 46 patients were included with a mean age of 16.1years (+/- 1.2). Most patients were male (41, 89%) and white (16, 44%). Initial management comprised chest tube drainage alone in 28 (61%), no intervention in 8 (17%), and VATS in 10 (22%). Total LOS was 6days (IQR 4-7) and was longer in patients who underwent VATS (p<0.001). Recurrence occurred in 17 patients (37%). However, recurrence and healthcare utilization were not significantly associated with initial management approach. Among those who had initial chest tube drainage, 14 (50%) underwent VATS on that admission, and 8 (28%) had subsequent surgery. Significant predictors of ultimately requiring VATS were presence of an air leak and partial lung expansion.

CONCLUSION

Most patients with PSP currently undergo chest tube placement as initial management, although most eventually require VATS. Presence of an air leak and partial lung expansion on chest radiograph within the first 48h of management should prompt earlier surgical intervention.

TYPE OF STUDY

Retrospective.

LEVEL OF EVIDENCE

III.

Recurrence rates in primary spontaneous pneumothorax: a systematic review and meta-analysis

Primary spontaneous pneumothorax (PSP) recurrence rates vary widely in the published literature, with limited data describing the factors that influence recurrence. The aims of this systematic review were to determine an estimation of PSP recurrence rates and describe risk factors for recurrence.

A systematic review was conducted of all studies reporting PSP recurrence. Electronic searches were performed to identify English language publications of randomised trials and observational studies. The population was adults with PSP, who underwent conservative management, pleural aspiration or chest drainage. The outcome of interest was recurrence. Articles were screened and data extracted from eligible studies by two reviewers.

Of 3607 identified studies, 29 were eligible for inclusion, comprising 13 548 patients. Pooled 1-year and overall recurrence rates were 29.0% (95% CI 20.9–37.0%) and 32.1% (95% CI 27.0–37.2%), respectively. Female sex was associated with increased recurrence (OR 3.03, 95% CI 1.24–7.41), while smoking cessation was associated with a four-fold decrease in risk (OR 0.26, 95% CI 0.10–0.63). I2 for random effects meta-analysis was 94% (p<0.0001), reflecting high heterogeneity between studies.

This systematic review demonstrates a 32% PSP recurrence rate, with greatest risk in the first year. Female sex was associated with higher risk, suggesting possible sex-specific pathophysiology.

Spontaneous Pneumothorax in Children: National Management Strategies and Outcomes

INTRODUCTION

The timing of surgical intervention in the management of spontaneous pneumothorax remains controversial. The aim of this multicenter review was to compare management strategies and outcomes in children with spontaneous pneumothorax.

METHODS

We retrospectively reviewed patients 10-19 years old in the Pediatric Health Information System admitted for spontaneous pneumothorax from 2010 to 2014. Three treatment groups were identified based on initial hospital management-no intervention, initial chest tube placement, and operation; and outcomes were compared.

RESULTS

A total of 1040 patients were included. The majority were male (82.1%) and White (71.1%). The mean age at first encounter was 15.7 ± 1.7 years. Initial treatment included no intervention in 336 (32.3%), chest tube in 497 (47.8%), and video-assisted thoracoscopic surgery (VATS) in 207 (19.9%). Ultimately, 417 (40.1%) patients underwent VATS during the initial admission and 559 (53.8%) during the initial admission or a subsequent encounter. Aggregate length of stay (LOS) was highest for those treated initially with chest tube alone (P < .001). For patients managed initially with chest tube, the probability of requiring surgery increased with each day of hospitalization. Initial operation was associated with a decreased risk of readmission (OR 0.67, 95% CI 0.50-0.90). Estimated adjusted hospital costs, aggregated across all encounters, were highest for chest tube alone (P < .001).

CONCLUSION

Early VATS is associated with decreased hospital LOS, charges, and readmissions. For those managed initially with chest tube alone, the likelihood of requiring operation increases with each day hospitalized, and early conversion to operative management should be considered in patients with persistent pneumothorax or air leak.

Association Between BMI and Recurrence of Primary Spontaneous Pneumothorax

BACKGROUND

Whether body mass index (BMI) is a significant risk factor for recurrence of primary spontaneous pneumothorax (PSP) remains controversial. The purpose of this study was to examine whether BMI and other factors are linked to risk of PSP recurrence.

METHODS

A consecutive cohort of 273 patients was retrospectively evaluated. Patients were divided into those who experienced recurrence (n = 81) and those who did not (n = 192), as well as into those who had low BMI (n = 75) and those who had normal or elevated BMI (n = 198). The two pairs of groups were compared in terms of baseline data, and Cox proportional hazards modeling was used to identify predictors of PSP recurrence.

RESULTS

Rates of recurrence among all 273 patients were 20.9% at 1 year, 23.8% at 2 years, and 28.7% at 5 years. Univariate analysis identified the following significant predictors of PSP recurrence: height, weight, BMI, size of pneumothorax, and treatment modality. Multivariate analyses identified several risk factors for PSP recurrence: low BMI, pneumothorax size ≥50%, and non-surgical treatment. Kaplan-Meier survival analysis indicated that patients with low BMI showed significantly lower recurrence-free survival than patients with normal or elevated BMI (P < 0.001).

CONCLUSIONS

Low BMI, pneumothorax size ≥50%, and non-surgical treatment were risk factors for PSP recurrence in our cohort. Low BMI may be a clinically useful predictor of PSP recurrence.

Association between postoperative bulla neogenesis at the staple line and resected lung weight for primary spontaneous pneumothorax: a retrospective study using the inverse-probability of treatment weighted method in patients grouped according to age

BACKGROUND

Bullectomy using autosutures is the standard procedure in patients with primary spontaneous pneumothorax (PSP). However, postoperative bulla neogenesis (POBN) along the staple line is relatively common and promotes PSP recurrence. We have previously reported the relationship between POBN and resected lung weight (LW). However, recently published data indicate that young patients with PSP have a high postoperative recurrence rate. Therefore, we evaluated the relationship between POBN and LW in PSP patients, subdivided according to age.

METHODS

Between February 2011 and April 2016, 96 lung-resection sites in 67 patients who underwent bullectomy were evaluated. Patients were subdivided into two groups by age: Y group (<25 years, 56 sites) and O group (≥25 years, 40 sites). We used the inverse-probability of treatment weighted (IPTW) method to adjust for the heterogeneity in their backgrounds. POBN was diagnosed by computed tomography.

RESULTS

Cox regression analysis for the O group indicated that LW ≥3.0 g was a significant risk factor for POBN (P=0.049). For the Y group, no association between lung weight and POBN was observed.

CONCLUSIONS

A LW ≥3.0 g is a significant risk factor for POBN in individuals aged ≥25 years.

Optimal surgical technique in spontaneous pneumothorax: a systematic review and meta-analysis

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.

Postoperative predictors of ipsilateral and contralateral recurrence in patients with primary spontaneous pneumothorax

BACKGROUND

Preventive surgery for contralateral recurrence of primary spontaneous pneumothorax (PSP) remains controversial and few studies discussed both ipsilateral and contralateral recurrences simultaneously. Thus, we aimed to identify the predictors of ipsilateral and contralateral PSP recurrence and to review literatures on the association of blebs/bullae on HRCT with PSP recurrence.

METHODS

We retrospectively reviewed consecutive patients who were treated at our hospital for first recurrence of PSP between January 2001 and December 2005.

RESULTS

This study included 553 patients who were followed-up for a mean period of 124 months. Ipsilateral and contralateral recurrence of PSP developed in 19.35% and 15.19% of patients, respectively. In the Cox regression analysis, the only significant predictors were no video-assisted thoracoscopic surgery (VATS) bullectomy (OR: 16.629, P<0.001) for ipsilateral recurrence, and the presence of blebs/bullae on HRCT (OR: 3.215, P=0.024) and low BMI (<18.5 kg/m²) (OR: 1.560, P=0.045) for contralateral recurrence.

CONCLUSIONS

VATS bullectomy was a strong independent predictor for prevention of ipsilateral PSP recurrence. Patients with contralateral blebs or bullae on chest HRCT or those with low BMI may be candidates for preventive VATS bullectomy to avoid recurrences and possible complications.

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.

Uniportal versus three-port video-assisted thoracoscopic surgery for spontaneous pneumothorax: a meta-analysis

BACKGROUND

Whether or not uniportal video-assisted thoracoscopic surgery (VATS) is beneficial for spontaneous pneumothorax remains inconclusive. This meta-analysis aimed to summarize the available evidence to assess the feasibility and advantages of uniportal VATS for the treatment of spontaneous pneumothorax compared with three-port VATS.

METHODS

Eligible publications were identified by searching the Cochrane Library, PubMed, EMBASE, Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang Data databases and CQVIP. Odds ratios (OR) and standardized mean differences (SMD) with 95% confidence intervals (CI) were calculated to compare dichotomous and continuous variables, respectively.

RESULTS

This meta-analysis was based on 17 studies and included a total of 988 patients with spontaneous pneumothorax. No death was reported during the perioperative period. Compared with three-port VATS groups, there was a statistically significant difference in uniportal VATS groups regarding postoperative hospital stay (SMD= -0.58; 95% CI: -1.04 to -0.12; P=0.01), paresthesia (OR=0.13; 95% CI: 0.07 to 0.24; P<0.00001), visual analogue pain score (VAS) at 24 hours (h) (SMD= -0.87; 95% CI: -1.07 to -0.68; P<0.00001), VAS at 72 h (SMD= -0.49; 95% CI: -0.68 to -0.30; P<0.00001), and patients satisfaction scale (PSS) at 24 h (SMD= -0.81; 95% CI: -1.21 to -0.41; P<0.0001), PSS at 48 h (SMD= -0.69; 95% CI: -1.08 to -0.29; P=0.0007). However there was no statistically significant difference on the recurrence (OR=0.79; 95% CI: 0.42 to 1.46; P=0.45), operative time (SMD= -0.23; 95% CI: -0.21 to 0.67; P=0.31), length of postoperative drainage (SMD= -0.17; 95% CI: -0.40 to -0.07; P=0.16), VAS at 48 h (SMD= -0.40; 95% CI: -1.47 to 0.67; P=0.46), and PSS at 72 h (SMD= -0.13; 95% CI: -0.52 to -0.25; P=0.50).

CONCLUSIONS

The results for mortality, recurrence, operative time, and length of postoperative drainage were similar between uniportal and three-port VATS. Uniportal VATS resulted in reduction in postoperative pain and paresthesia as well as an improvement in patients' satisfaction. This meta-analysis indicated that using uniportal VATS to treat spontaneous pneumothorax was safe and feasible, and it may be a better alternative procedure because of its advantage in reducing postoperative pain and paresthesia.