Risk factors of postoperative recurrence of primary spontaneous pneumothorax

Risk factors and age-specific monthly patterns of primary spontaneous pneumothorax: a multicenter study

Background

Primary spontaneous pneumothorax (PSP) is characterized by sudden lung collapse without external injury or underlying lung disease. However, detailed research on its causes and recurrence patterns is lacking, prompting investigating monthly epidemiology and factors influencing recurrence. Therefore, we aimed to assess the monthly trends in PSP occurrence and identify factors contributing to its recurrence, with a focus on teenagers due to the high incidence rates in this population, while also examining risk factors across other age groups.

Methods

We conducted a multicenter retrospective study involving 4,231 cases of PSP from five hospitals in Korea. Patients aged 10-39 years were included, wherein monthly incidence patterns were assessed. Statistical analyses using physical parameters and laboratory data were performed to determine factors influencing recurrence.

Results

Our analysis revealed that July was the most common diagnosis month in teenagers, followed by October and March. This month-based pattern differed from that observed in the other age groups. Multivariate analysis revealed body mass index (BMI) at initial diagnosis to be a significant risk factor for first recurrence in male patients aged 16-19 years [hazard ratio (HR), 0.98; 95% confidence interval (CI): 0.97-0.99; P=0.001] and in male patients older than 20 years (HR, 0.99; 95% CI: 0.98-0.99; P<0.001). In male patients aged ≥20 years, the monocyte-lymphocyte ratio (MLR) at initial diagnosis was also a significant factor for first recurrence (HR, 1.20; 95% CI: 1.10-1.32; P<0.001). In female patients aged ≥20 years, MLR at the time of the first pneumothorax was significantly associated with recurrence (HR, 1.41; 95% CI: 1.07-1.87; P=0.01).

Conclusions

Our study provided valuable insights into the month-based epidemiology of PSP in Korea, highlighting differences in incidence patterns among teenagers compared with those in the other age groups. Moreover, the reported link between BMI, inflammation, and pneumothorax recurrence might be a basis for future prospective studies aimed to prevent and treat pneumothorax.

Predicting recurrence in primary spontaneous pneumothorax: The role of the Haller index in emergency department patients

BACKGROUND

Primary spontaneous pneumothorax (PSP) is a common condition encountered in emergency departments, typically affecting young, otherwise healthy individuals. Identifying patients at risk for recurrence is critical for optimizing management strategies and preventing complications. This study aimed to evaluate the predictive value of the Haller index in determining the risk of recurrence in patients diagnosed with PSP.

METHODS

A retrospective analysis was conducted on patients diagnosed with PSP between January 1, 2019 and January 1, 2024, in the emergency department of a tertiary care hospital. Patients were categorized into two groups: those experiencing a single PSP episode and those with recurrent pneumothorax. Propensity score matching was employed to control for confounders, including age, gender, smoking status, and body mass index (BMI). The Haller index was calculated from chest computed tomography (CT) scans, and its predictive accuracy for recurrence was evaluated using Receiver Operating Characteristic (ROC) curve analysis.

RESULTS

A total of 182 patients were included in the study, with 91 patients in each group after propensity score matching. The Haller index was significantly higher in the recurrent pneumothorax group (2.72+-0.47) compared to the single pneumothorax group (2.15+-0.34), with a mean difference of 0.56 (95% confidence interval [CI]: 0.44-0.69, p<0.001). ROC analysis demonstrated an area under the curve (AUC) of 0.830 (95% CI: 0.768-0.882), with a Youden index of 0.50, sensitivity of 72.53%, and specificity of 76.92% for a cutoff value of >2.38.

CONCLUSION

The Haller index is a strong predictor of recurrent pneumothorax in patients with PSP. Its integration into clinical assessments can help identify patients at elevated risk of recurrence, enabling tailored treatment strategies.

Evaluation of the nonstapling bullectomy by manual suturing for young men with primary spontaneous pneumothorax

Background

Currently, surgery for primary spontaneous pneumothorax (PSP) is performed by bullectomy using a stapler with complete video-assisted thoracic surgery (cVATS). However, the postoperative recurrence rate (RR) of PSP is high in young men. The factors of postoperative PSP recurrence are the formation of postoperative bulla neogenesis (POBN) around the staple line, pleural injury caused by forceps for VATS, and bulla overlooked with a thoracoscope. We attempted nonstapling bullectomy with one-port-one-window (1p-1w) by using hybrid VATS (hVATS) to reduce postoperative RR. This study aimed to evaluate nonstapling bullectomy by manual suturing for young male patients with PSP compared with bullectomy by cVATS.

Methods

From January 2012 to December 2022, we retrospectively reviewed the medical records of 259 male patients aged ≤25 years who underwent initial surgery for PSP and compared them between two groups, with staple use (S+) or by manual suturing without staple use (S-). RR, operative time, blood loss, and postoperative hospitalization period were examined in both groups.

Results

The median operative time was 81 and 63 min in the S- and S+ groups, respectively (P<0.001), with the S- group tending to be statistically significantly longer. The mean intraoperative blood loss was 1.61 and 2.11 mL in the S- and S+ groups, respectively (P=0.003). The median postoperative hospitalization period was 4 days in both groups (P=0.32). Recurrences occurred in 8 (7.1%) and 14 patients (12.2%) in the S- and S+ groups, respectively [odds ratio (OR) =0.55; 95% confidence interval (CI): 0.22-1.37; P=0.19]. In patients aged <20 years, 5 (6.6%) and 10 (14.1%) patients had a recurrence in the S- and S+ groups, respectively (OR =0.42; 95% CI: 0.13-1.32; P=0.13).

Conclusions

Compared with stapling bullectomy, nonstapling bullectomy with small thoracotomy for young male patients with PSP had lesser RR. This procedure is beneficial in reducing postoperative recurrence and is one of the surgical choices for young male patients with PSP.

Prospective Observation Study for Primary Spontaneous Pneumothorax: Incidence of and Risk Factors for Postoperative Neogenesis of Bullae

PURPOSE

Details of the neogenesis of bullae (NOB), which causes recurrent primary spontaneous pneumothorax (PSP) following bullectomy, have not been reported and risk factors for NOB remain unclear. We aimed to clarify the details of NOB.

METHODS

We conducted a prospective study using three computed tomography (CT) examinations performed 6, 12, and 24 months after bullectomy to identify the incidence of and risk factors for NOB. We enrolled 50 patients who underwent bullectomy for PSP.

RESULTS

After excluding 11 patients who canceled the postoperative CT examination at 6 months after bullectomy, only 39 patients were analyzed. The incidence of NOB at 6, 12, and 24 months after bullectomy was 38.5%, 55.2%, and 71.2%, respectively. The rate of NOB in the operated lung was almost 2 times higher than that in the contralateral nonoperative lung. Male sex, multiple bullae on preoperative CT, long stapling line (≥7 cm), deep stapling depth (≥1.5 cm), and heavier resected sample (≥5 g) were suggested to be risk factors for NOB.

CONCLUSIONS

We recognized a high incidence of postoperative NOB in PSP patients. Bullectomy itself seems to promote NOB. Postoperative NOB occurs frequently, especially in patients who require a large-volume lung resection with a long staple line.

Adhesion is a risk factor for postoperative recurrence of spontaneous pneumothorax

Background

Several risk factors for postoperative recurrence of spontaneous pneumothorax have been reported, but the identified risk factors differed among studies.

Methods

A total of 183 primary spontaneous pneumothorax patients were enrolled in this retrospective study, and the risk factors for postoperative recurrence were evaluated.

Results

Among the patients, more than 80% with ipsilateral postoperative recurrence (IPR) relapsed within 3 years and more than 80% with contralateral postoperative recurrence relapsed within 4 years. Compared with patients without IPR, patients with IPR had significantly more cases with history of pneumothorax (P<0.10), more cases without preoperative drainage (P=0.02), more cases with intraoperative adhesion (P<0.01), greater upward lung volume (P=0.04), more numbers of automatic sutures (P=0.04), and more cases with contralateral recurrence (P<0.01). Furthermore, compared with patients without adhesion, patients with adhesion had significantly older age (P<0.01), and more cases with adhesion on CT images (P<0.01). Patients with adhesion also had significantly greater upward lung volume (P<0.01), more cases that received covering with polyglycolic acid (PGA) sheet covering with fibrin glue (P=0.01), and more cases that received re-do surgery (P=0.04). IPR was significantly more common in the adhesion group (P<0.01), while contralateral postoperative recurrence did not differ significantly between the groups with and without adhesion (P=0.06). Univariate analyses showed that body mass index (BMI) <15.6 kg/m2 (P<0.01), history of pneumothorax (P=0.01), intraoperative adhesion (P<0.01), upward lung volume >80% (P=0.02), lateral lung volume >80% (P=0.02), 3 fire or more of automatic sutures (P=0.03), and contralateral recurrence (P=0.01) were significant risk factors for IPR. BMI <15.6 kg/m2 (odds ratio: 20.89; 95% confidence interval: 1.55-280.70; P=0.02) and intraoperative adhesion (odds ratio: 25.58; 95% confidence interval: 1.91-342.39; P=0.01) were identified as risk factors for IPR in a multivariate analysis.

Conclusions

The present findings suggest that low BMI and intraoperative adhesion are risk factors for postoperative recurrence of spontaneous pneumothorax. For such patients, additional intraoperative procedures, such as covering with PGA sheet absorbable oxidized cellulose may be required to reduce postoperative recurrence.

SPLF/SMFU/SRLF/SFAR/SFCTCV Guidelines for the management of patients with primary spontaneous pneumothorax

INTRODUCTION

Primary spontaneous pneumothorax (PSP) is the presence of air in the pleural space, occurring in the absence of trauma and known lung disease. Standardized expert guidelines on PSP are needed due to the variety of diagnostic methods, therapeutic strategies and medical and surgical disciplines involved in its management.

METHODS

Literature review, analysis of the literature according to the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) methodology; proposals for guidelines rated by experts, patients and organizers to reach a consensus. Only expert opinions with strong agreement were selected.

RESULTS

A large PSP is defined as presence of a visible rim along the entire axillary line between the lung margin and the chest wall and ≥ 2 cm at the hilum level on frontal chest X-ray. The therapeutic strategy depends on the clinical presentation: emergency needle aspiration for tension PSP; in the absence of signs of severity: conservative management (small PSP), needle aspiration or chest tube drainage (large PSP). Outpatient treatment is possible if a dedicated outpatient care system is previously organized. Indications, surgical procedures and perioperative analgesia are detailed. Associated measures, including smoking cessation, are described.

CONCLUSION

These guidelines are a step towards PSP treatment and follow-up strategy optimization in France.

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.

SPLF/SMFU/SRLF/SFAR/SFCTCV Guidelines for the management of patients with primary spontaneous pneumothorax: Endorsed by the French Speaking Society of Respiratory Diseases (SPLF), the French Society of Emergency Medicine (SFMU), the French Intensive Care Society (SRLF), the French Society of Anesthesia & Intensive Care Medicine (SFAR) and the French Society of Thoracic and Cardiovascular Surgery (SFCTCV)

INTRODUCTION

Primary spontaneous pneumothorax (PSP) is the presence of air in the pleural space, occurring in the absence of trauma and known lung disease. Standardized expert guidelines on PSP are needed due to the variety of diagnostic methods, therapeutic strategies and medical and surgical disciplines involved in its management.

METHODS

Literature review, analysis of literature according to the GRADE (Grading of Recommendation Assessment, Development and Evaluation) methodology; proposals for guidelines rated by experts, patients, and organizers to reach a consensus. Only expert opinions with strong agreement were selected.

RESULTS

A large PSP is defined as presence of a visible rim along the entire axillary line between the lung margin and the chest wall and ≥2 cm at the hilum level on frontal chest x-ray. The therapeutic strategy depends on the clinical presentation: emergency needle aspiration for tension PSP; in the absence of signs of severity: conservative management (small PSP), needle aspiration or chest tube drainage (large PSP). Outpatient treatment is possible if a dedicated outpatient care system is previously organized. Indications, surgical procedures and perioperative analgesia are detailed. Associated measures, including smoking cessation, are described.

CONCLUSION

These guidelines are a step towards PSP treatment and follow-up strategy optimization in France.

Oxidized Regenerated Cellulose versus Polyglycolic Acid for Pleural Coverage in Pneumothorax Surgery

Objectives: Although surgical intervention for spontaneous pneumothorax (SP) reduces the recurrence rate, thoracoscopic surgery is associated with greater postoperative recurrence rates than open thoracotomy. A polyglycolic acid (PGA) sheet or oxidized regenerated cellulose (ORC) mesh can therefore be used for additional coverage after thoracoscopic surgery, and this study compared the clinical impacts of these two materials. Methods: From 2018 to 2020, 262 thoracoscopic surgeries for primary SP were performed, of which 125 patients were enrolled in this study, and 48 and 77 patients received ORC and PGA coverage, respectively. The clinical characteristics and surgical procedures were reviewed, and the recurrence rates were compared. To obtain more comprehensive evidence, we performed a literature review and meta-analysis comparing ORC and PGA coverage. Results: There were no significant differences in patient characteristics between the two groups. Operating time was slightly shorter in the ORC group than in the PGA group (p = 0.008). The pneumothorax recurrence rate was similar in both groups (PGA: 10.4%, ORC: 6.2%, p = 0.529), but the recurrence-free interval was significantly longer (p = 0.036) in the ORC (262 days) than in the PGA (48.5 days) group. The literature review identified three relevant studies, and the meta-analysis revealed no difference in pneumothorax recurrence rate between the two coverage materials. Conclusions: The two visceral pleural coverage materials, PGA and ORC, did not show significant differences in postoperative pneumothorax recurrence. Therefore, if applied appropriately, the choice of material between ORC and PGA for thoracoscopic pneumothorax surgery does not have a significant impact on the clinical outcome.

A No-Chest-Drain Policy After Video-assisted Thoracoscopic Surgery Wedge Resection in Selected Patients: Our 12-Year Experience

BACKGROUND

Postoperative pleural drainage omission after video-assisted thoracoscopic surgery (VATS) for wedge resections may facilitate faster recovery. This retrospective cohort study presents our 12-year experience with omitting thoracic drainage in patients who underwent a VATS wedge resection, aiming to assess its safety and efficacy.

METHODS

Records from consecutive patients who underwent a VATS wedge resection at our hospital between February 2008 and October 2020 were retrospectively reviewed and assessed for eligibility. Patient and surgical characteristics as well as postoperative data were collected and compared between patients who received a chest drain (CD) or received no chest drain (NCD) after surgery. Univariable and multivariable analyses were performed to determine whether drain placement was associated with complications (primary outcome), and major complications requiring pleural drainage or length of hospital stay (secondary outcomes).

RESULTS

Data of 348 patients were analyzed. The drainless group (n = 98) and drain group (n = 237) were significantly different in the following baseline and surgical characteristics: sex, pulmonary function, interstitial lung disease, final pathology, number of wedges, and surgical approach. No significant differences were detected in postoperative complications (NCD 8.2%, CD 14.8%; P = .10), major complications (NCD 5.1%, CD 5.1%; P > .99), or complications requiring pleural drainage (NCD 5.1%, CD 3.8%; P = .56). The drainless group did show a significantly shorter hospitalization (NCD 2 ± 2, CD 3 ± 2 days; P < .001). Multivariable analyses revealed that drain placement was not significantly correlated with postoperative complications. In contrast, prolonged hospitalization was significantly influenced by drain placement.

CONCLUSIONS

Our findings suggest that a no-chest-drain policy after VATS wedge resections can safely fast-track rehabilitation for selected patients.

Manejo quirúrgico del neumotórax espontáneo primario. Encuesta nacional del Grupo Emergente de Cirugía Torácica de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR)

Introduction

In February 2022, the Emerging Thoracic Surgery Group of the Spanish Society of Pneumology and Thoracic Surgery initiated a multicenter study on the surgical management of primary spontaneous pneumothorax (PSP). As a preliminary step, this survey was developed with the aim of finding out the current situation in our country to specify and direct this project.

Method

A descriptive study was carried out based on the results of this survey launched through the Google Docs® platform. The survey was sent to all active national thoracic surgeons, a total of 319. It consisted of 20 questions including demographic, surgical and follow-up data.

Results

We obtained 124 responses (39% of all specialists and doctors in training in the national territory). The most consistent indications were: homolateral recurrence for 124 (100%), lack of resolution of the episode for 120 (96.7%), risk professions for 104 (84%) and bilateral pneumothorax for 93 (75%). The approach of choice for 100% of respondents was videothoracoscopy. Of these, 96 contemplated pulmonary resection of obvious lesions (77%). Regarding the pleurodesis technique, pleural abrasion was the technique most used by 70 respondents (56.7%) while 49 (40%) performed chemical pleurodesis with talc either alone or in combination with mechanical pleurodesis.

Conclusions

While there is some consistency in some aspects of surgical management of PSP, this survey makes evident the variability in pleurodesis techniques applied among surgeons in our country.

Recommandations formalisées d’experts pour la prise en charge des pneumothorax spontanés primaires

Introduction : Le pneumothorax spontané primaire (PSP) est un épanchement gazeux dans la cavité pleurale, survenant hors traumatisme et pathologie respiratoire connue. Des recommandations formalisées d'experts sur le sujet sont justifiées par les pluralités de moyens diagnostiques, stratégies thérapeutiques et disciplines médicochirurgicales intervenant dans leur prise en charge.

Méthodes : Revue bibliographique, analyse de la littérature selon méthodologie GRADE (Grading of Recommendation Assessment, Development and Evaluation) ; propositions de recommandations cotées par experts, patients et organisateurs pour obtenir un consensus. Seuls les avis d'experts avec accord fort ont été retenus.

Résultats : Un décollement sur toute la hauteur de la ligne axillaire et supérieur ou égal à 2 cm au niveau du hile à la radiographie thoracique de face définit la grande abondance. La stratégie thérapeutique dépend de la présentation clinique : exsufflation en urgence pour PSP suffocant ; en l'absence de signe de gravité : prise en charge conservatrice (faible abondance), exsufflation ou drainage (grande abondance). Le traitement ambulatoire est possible si organisation en amont de la filière. Les indications, procédures chirurgicales et l'analgésie périopératoire sont détaillées. Les mesures associées, notamment le sevrage tabagique, sont décrites.

Conclusion : Ces recommandations sont une étape de l'optimisation des stratégies de traitement et de suivi des PSP en France.

Risk of Pneumothorax Requiring Pleural Drainage after Drainless VATS Pulmonary Wedge Resection: A Systematic Review and Meta-Analysis

OBJECTIVE

Omitting pleural drainage after video-assisted thoracic surgery (VATS) for pulmonary wedge resections has been shown to be a safe approach to enhance recovery. However, major concerns remain regarding the risk of postoperative pneumothoraces requiring surgical interventions. Therefore, our objective was to provide conclusive evidence whether chest tube omission after VATS wedge resection is safe and does not increase the risk of pneumothoraces requiring pleural drainage.

METHODS

Five scientific databases were searched. Studies comparing patients with (CT group) and without chest tube drainage (NCT group) after VATS wedge resection were evaluated. Outcomes included radiographically diagnosed pneumothoraces and pneumothoraces requiring pleural drainage, postoperative complications, hospitalization, and pain scores.

RESULTS

Overall, 9 studies (3 randomized controlled trials) were included (N = 928). Meta-analysis showed significantly more radiographically diagnosed pneumothoraces in the NCT group (risk ratio [RR] = 2.58, 95% confidence interval [CI]: 1.56 to 4.29, P < 0.001; I² = 0%). However, no significant differences were found in postoperative pneumothoraces requiring pleural drainage (RR = 1.72, 95% CI: 0.63 to 4.74, P = 0.29; I² = 0%) or complications (RR = 0.77, 95% CI: 0.39 to 1.52, P = 0.46; I² = 0%). Furthermore, the NCT group showed significantly shorter hospitalization (mean difference = -1.26, 95% CI: -1.56 to -0.95, P < 0.001) with high heterogeneity (I² = 58%, P = 0.02), and lower pain scores on postoperative day 1 (standard mean difference [SMD] = -0.98, 95% CI: -1.71 to -0.25, P = 0.009; I² = 92%) and postoperative day 2 (SMD = -1.28, 95% CI: -2.55 to -0.01, P = 0.05; I² = 96%) compared with the CT group.

CONCLUSIONS

VATS wedge resection without routine chest tube placement is suggested as a safe and less invasive approach in selected patients that does not increase the risk of a pneumothorax requiring pleural drainage.

Early Postoperative Pneumothorax Might Not Be 'True' Recurrence

Objectives: To date, there is no consensual definition of what constitutes a postoperative recurrence of primary spontaneous pneumothorax (PSP), despite there being many studies reporting a high incidence of recurrence. This study aims to describe the long-term recurrence rates of pneumothorax and to suggest a possible way to differentiate recurrence events based on temporal patterns. Methods: This single-center study retrospectively evaluated all postoperative recurrence of PSP from January 2007 to May 2019. Patients’ demographics, history of pneumothorax, radiologic data, surgical technique, and the time between operation and recurrence were analyzed. Univariate and multivariable analyses were conducted to find potential risk factors related to long-term recurrence. Results: Of the 77 postoperative recurrent cases of pneumothorax, 21 (27.2%) occurred within 30 days after surgery and, thus, were classified as early recurrences (ER), while the remaining cases were classified as late recurrences (LR). There was no difference in preoperative variables between the two groups. However, the rate of incidence of second recurrence (SR), which represented a long-term prognosis, was significantly higher in the LR group (28.6% vs. 4.8%, p = 0.030). On univariate and multivariable analyses, late recurrence was the only significant factor predicting later recurrence events. Conclusion: Postoperative recurrence (PoR) within 30 days had a lower SR rate. Therefore, it might not be a ‘true’ postoperative recurrence with a favorable prognosis. Further studies investigating postoperative recurrence based on temporal patterns would be warranted to improve the classification of PoR.

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.