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

Abstract

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.

Incidence and risk factors for recurrent primary spontaneous pneumothorax after video-assisted thoracoscopic surgery: a systematic review and meta-analysis

“…Fifteen studies ( 27 - 30 , 32 - 39 , 41 - 43 ) reported the sex of patients; of a total of 4,128 patients (female: n=601; male: n=3,527), 384 experienced recurrence. The forest plot for sex revealed a significant OR of 0.61 (95% CI: 0.41–0.92; P=0.02) with non-significant heterogeneity (I 2 =0%; P=0.74) ( Figure 6 ) and an asymmetrical funnel plot in the appendix available at https://cdn.amegroups.cn/static/public/jtd-24-175-1.docx .…”

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

“…It is usually achieved by stapling or sectioning the lung parenchyma with an automatic forceps. In the absence of a detectable lesion, an atypical parenchymal resection at the apex may be performed [ 156 ], contributing to subsequent pleurodesis, and allowing pathological analysis of the underlying lung. The use of aerostatic material has been suggested in order to cover the stapling line, to reduce the risk of recurrence [ 157 ].…”

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

“…16,17) They suggested that the resected lung volume influenced the recurrence of PSP. 18,19) It is reasonable to hypothesize that lung deformation following large lung resection and high pressure at lung expansion on the stapling lines induced NOB. It is easy to imagine that the middle part of the stapling will be exposed to high pressure at lung expansion in the early postoperative period.…”