Recurrence of primary spontaneous pneumothorax following bullectomy with pleurodesis or pleurectomy: A retrospective analysis

Abstract

Background: Primary spontaneous pneumothorax is managed initially with observation and chest tube placement, followed by surgical intervention in select cases. With little currently published evidence, the role of surgical pleurodesis or pleurectomy to reduce primary spontaneous pneumothorax recurrence is unclear.This study compares the recurrence rates of primary spontaneous pneumothorax following bullectomy alone versus bullectomy with pleurodesis or pleurectomy. Methods: A retrospective review was performed at a quaternary hospital for all patients undergoing surgery for primary spontaneous pneumothorax between June 2006 and December 2018. Patient demographics, disease severity, operative technique, and time between initial surgery and recurrence were recorded.Standard statistical techniques were used for univariable and multivariable analyses. Results: Of 222 total included patients, 28 required a second surgery: 4 (1.8%) for prolonged air leak and 24 (10.8%) for recurrent pneumothorax. The median time from first to second surgery was 363 days and 35.7% of recurrences did not present until after two years. Age, sex, smoking, year of initial surgery, disease severity, and surgical technique did not significantly affect recurrence rate on univariable analysis.On multivariable analysis, the odds ratios of recurrence for bullectomy with mechanical pleurodesis or pleurectomy were respectively 0.82 and 0.15 (P=0.218), compared to bullectomy alone. Combined bullectomy, pleurectomy, and pleurodesis was most effective (0/18, 0%). Conclusions: Bullectomy with pleurectomy and pleurodesis demonstrated a 0% recurrence rate for the treatment of primary spontaneous pneumothorax in this study. Statistical significance was not achieved in univariable or multivariable analyses comparing recurrence rates for the surgical approaches. A multi-center randomized controlled trial with longer follow-up than previously performed is needed to confirm these preliminary findings and optimize surgical management of primary spontaneous pneumothorax.

Early Postoperative Pneumothorax Might Not Be ‘True’ Recurrence

“…This study analyzed 77 cases of PoR and explained that the temporal patterns of recurrence might be predictive of SR. As we described in Figure 1 , 27.3% (21/77) of the cases of PoR occurred within 30 days after surgery. This result is similar to the findings of Brophy et al, which showed that 26.3% (10/38) of PoR occurred within 30 days after surgery [ 8 ]. Moreover, patients in the ER group showed a better prognosis in terms of developing recurrent pneumothorax down the road than those in the LR group, and the period between surgery and recurrence played a significant prognostic factor.…”

“…To date, there has not been a clear consensus on the definition of postoperative recurrence of PSP. Brophy et al described a “true” postoperative recurrence as an episode that occurs at least 15 days after surgery and classified repetitive pneumothorax within 15 days as a “prolonged air leak” [ 8 ]. Onuki et al defined recurrence as an episode occurring at least 30 days after surgery and thought that recurrent events within the first 30 days after surgery were part of the staple-healing process [ 10 ].…”

“…Therefore, there has been a considerable amount of research to determine the potential risk factors predicting the postoperative recurrence (PoR) of PSP. Many surgical procedures, such as mechanical pleurodesis, pleural abrasion, pleurectomy, and coverage materials, have been introduced to reduce postoperative PSP [ 1 , 3 , 4 , 5 , 6 , 7 , 8 ]. However, to the best of our knowledge, a study about patients with PoR and their long-term recurrence-free survival has not yet been investigated.…”

“…In addition, there is currently no clearly established and consensual definition of what constitutes a recurrence of pneumothorax after surgery [ 8 , 9 ]. When previous studies classified recurrence, they lacked a clear explanation about the timing, or time pattern, of PoR.…”

Special Issue on “Clinical Research of Spontaneous Pneumothorax”

“…Woo and colleagues attempted in their study to suggest a new classification system for the postoperative recurrence of SP [ 4 ] and tried to identify risk factors that could be related to a second recurrence. Following other reports, authors concluded that a pneumothorax occurring within 30 days from surgery should not be considered a true recurrence but part of the healing process [ 4 , 28 , 29 ]. They demonstrated that patients with postoperative recurrence within 30 days showed a better prognosis than patients with late recurrent episodes.…”