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Department of Cardiothoracic Surgery, Guy's Hospital, St. Thomas St, London, SE1 9RT United Kingdom
(Email: loic.lang-lazdunski{at}gstt.nhs.uk).
Primary spontaneous pneumothorax (PSP) remains one of the most frequently treated conditions in thoracic practice. The American College of Chest Physicians, the British Thoracic Society, and other scientific societies have published guidelines for the management of this condition.
Current indications for surgical referral include persistent air leak (> 5 days), ipsilateral recurrence, bilateral pneumothorax, tension pneumothorax, hemopneumothorax, and occupational hazard.
In most countries, a patient presenting with a first episode of PSP will be conservatively managed with pleural aspiration or closed tube thoracostomy. It is assumed that 50% to 70% of patients with PSP will never experience an ipsilateral recurrence.
Surgery for PSP videothoracoscopic approach probably less than a thoracotomy, can result in significant morbidity (ie, severe bleeding requiring transfusion, empyema, nerve injury, and long-term chest pain or discomfort, particularly debilitating in this young patient population. Therefore, precise selection criteria should be used to select the appropriate candidates for surgery at first episode and avoid unnecessary morbidity in the others.
Recent studies have suggested that VATS bullectomy and pleurodesis at first episode might result in less morbidity and lower cost than conventional management.
Ryu and colleagues [1] show that patients presenting with a complete pneumothorax and total lung atelectasis at first episode are three times more likely to need surgery at first sight (29.4% vs 10%; p = 0.0001) and much more likely to need surgery subsequently than patients with partial atelectasis (70% vs 39.2%; p = 0.0001). At follow-up, 78.8% of patients with total atelectasis ended up having VATS blebectomy and pleural abrasion versus 45.3% in the partial atelectasis group, a highly significant difference (p = 0.0001).
Although this study is retrospective in nature, patients in both groups were similar for gender, age, body mass index, smoking habit, and operative findings (number of blebs and bullae). The authors suggest that total lung atelectasis is caused by a ruptured subpleural bleb and a one-way valve air leak mechanism making the likelihood of spontaneous healing improbable.
Should these findings and observations been confirmed by a prospective trial, it may well be that we shall add another entry to the list of surgical indications at first episode in patients presenting with PSP.
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