Recurrence after VATS pleurodesis for primary spontaneous pneumothorax: can surgeons minimize the risk?

Abstract

OBJECTIVE: A minority of patients experience recurrence following pleurodesis via video-assisted thoracoscopic surgery (VATS) for primary spontaneous pneumothorax (PSP). To reduce recurrence, its risk factors must first be identified. METHODS: VATS bleb staple-excision and mechanical pleurodesis was performed in 315 consecutive patients with PSP. Patients with previous pleurodesis and/or secondary pneumothorax were excluded. Recurrence was defined as any new clinically or radiographically detected ipsilateral pneumothorax following surgery. RESULTS: The cohort included 284 males (90.2%), and had a median age of 21 years (range: 15–40). After a median follow-up of 72.4 months (range: 32.5–106.8 months), recurrent pneumothorax occurred in 41 patients (13.0%), including 19 requiring re-intervention (6.0%). Survival analysis demonstrated significant association of recurrence with: age ≤ 25 years (HR = 2.82, 95% CI 1.43–5.56, p = 0.023); operation time > 60 minutes (HR = 2.39, 95% CI 0.97–5.90, p = 0.020); and residual inter-pleural air space on chest X-ray after chest drain removal (HR = 1.99, 95% CI 1.05–3.79, p = 0.024). A trend of association of recurrence with a pain score > 2 (10-point visual analog scale) on coughing on post-op day 1 was observed (HR = 2.46, 95% CI 1.18–6.47, p = 0.082). Other patient factors (including sex, smoking history, symptoms), intraoperative factors (including laterality, surgery performed by trainee, needlescopic VATS, adjunct chemical pleurodesis) and postoperative factors (including air leak, chemical pleurodesis, stopping suction before drain removal, prolonged drain durations) did not show association with recurrence. CONCLUSION: Risk factors associated with recurrence after VATS for PSP may potentially be controllable by the surgeon. Expeditious surgery, careful drain removal to prevent residual air space, and aggressive postoperative pain control may help to minimize recurrence risk.