Postoperative Pneumothorax Recurrence Research Articles

Risk factors for the recurrence of primary spontaneous pneumothorax after video-assisted thoracoscopic surgery in patients younger than 40 years.

Video-assisted thoracoscopic surgery (VATS) is a standard primary spontaneous pneumothorax (PSP) procedure. However, its high recurrence rate compared to open thoracotomy is a problem. Therefore, various methods to prevent recurrence have been developed. The present study investigated the risk factors for postoperative recurrence of PSP after VATS. From January 2008 to November 2022, 207 patients younger than 40 years of age without underlying pulmonary disease underwent thoracoscopic bullectomy for PSP. Among them, 96 underwent staple line reinforcement with a polyglycolic acid (PGA) sheet and autologous blood spraying. Patient characteristics and surgical outcomes were analyzed to determine the prognostic factors for postoperative recurrence. Twenty-seven patients (13.0%) experienced recurrences. A multivariate analysis using Cox regression analysis revealed that age younger than 20 years [P=0.039; hazard ratio (HR) =2.337; 95% confidence interval (CI): 3.283-17.287], history of contralateral pneumothorax (P<0.001; HR =7.533; 95% CI, 1.486-12.336), and no staple line reinforcement (P=0.007; HR =4.282; 95% CI, 1.043-5.236) were risk factors for recurrence after pneumothorax surgery. Age younger than 20 years and history of contralateral pneumothorax were risk factors for postoperative recurrence of pneumothorax. Staple line reinforcement with a PGA sheet and spraying of autologous blood reduced the postoperative recurrence rate of PSP.

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.

Reduced risk of recurrent pneumothorax for sirolimus therapy after surgical pleural covering of entire lung in lymphangioleiomyomatosis

BackgroundPatients with lymphangioleiomyomatosis (LAM) frequently experience pneumothorax. Although sirolimus is the standard therapy for LAM, its effect on pneumothorax is controversial. Recently, total pleural covering (TPC) and modified TPC (mTPC) were introduced as surgical treatment options for pneumothorax for patients with LAM. However, the effect of sirolimus on the recurrence of pneumothorax in patients who underwent the treatments is still uncertain. We hypothesized that some clinical factors including sirolimus treatment could predict postoperative recurrence of pneumothorax. In order to clarify this hypothesis, we retrospectively analyzed the clinical data from 18 consecutive patients with LAM who underwent 24 surgical pleural covering of entire lung (SPC) as 17 TPC and 7 mTPC against pneumothoraces from surgical database between January 2005 and January 2019, and we determined the predictors of postoperative recurrence.ResultsOf the 24 surgeries of SPC, 14 surgeries (58.3%) had a history of two or more ipsilateral pneumothoraces, and 11 surgeries (45.8%) had a history of ipsilateral pleural procedures before SPC. Sixteen surgeries (66.6%) in 12 patients received treatment of sirolimus after SPC (sirolimus group). With a median follow-up time of 69.0 months after SPC, four surgeries (16.6%) in three patients had a postoperative recurrence, and the 5-year recurrence-free survival (RFS) after SPC was 82.9%. In patients with postoperative recurrence, serum level of vascular endothelial growth factors D was significantly higher than that in those with non-recurrence (3260.5 vs. 892.7 pg/mL, p = 0.02), and the rate of sirolimus treatment in the recurrence group was significantly lower than that in the no-recurrence group (0 vs. 80%, p = 0.006). The log-rank test showed that the RFS of the sirolimus group (sirolimus use after SPC) was significantly better than that of the non-sirolimus group (p = 0.001), and no significant difference was observed for other factors.ConclusionWe first reported sirolimus might effectively suppress the recurrence of pneumothoraces in LAM patients who received SPC. Sirolimus induction after SPC (TPC or mTPC) might be a feasible option for frequent pneumothorax in LAM.

Feasibility of application of an absorbable topical collagen hemostat sheet (INTEGRAN®) for prevention of postoperative recurrence of pneumothorax in youths.

BackgroundStaple-line coverage is an effective method for prevention of postoperative recurrence of pneumothorax. However, the recurrence rate in young patients is still unsatisfactory using this method. Moreover, there is no consensus about the optimal material for use in this technique. To explore new material for this technique, we conducted this study to evaluate the safety of an absorbable topical collagen hemostat (INTEGRAN®) for staple-line coverage in pneumothorax surgery in young patients.MethodsA single-arm prospective interventional study was performed in 25 patients (age <25 years old) with primary spontaneous pneumothorax (PSP) who underwent wedge resection with staple-line coverage with INTEGRAN® between 2017 and 2020. The rate of material-related adverse events (defined as a body temperature ≥38 ℃ continuing for ≥2 days, postoperative WBC >18,000/mm3 and/or CRP >15 mg/dL, or acute empyema within 30 postoperative days) was defined as the primary endpoint. The 1-year postoperative rates of recurrence and of new bullae around the staple-line were also measured.ResultsThe median age was 19 years old. None of the patients had a body temperature ≥38 ℃ continuing for ≥2 days, extra-abnormal examination data, and acute empyema findings. At 1-year postoperatively, the recurrence rate was 12.0%, and the rate of new bullae around the staple-line was 16.7%.ConclusionsThis study showed the safety of use of INTEGRAN® for staple-line coverage in pneumothorax surgery in young adults. The short-term recurrence rate was acceptable given the high-risk cohort examined in the study. A prospective randomized controlled study is needed for evaluation of the efficacy of INTEGRAN® for prevention of recurrence of PSP.Trial RegistrationUMIN000026530 at UMIN Clinical Trials Registry

Efficacy of pleural coverage with polyglycolic acid sheet after bullectomy for postoperative recurrence of spontaneous pneumothorax in young patients: a multi-institutional cohort study.

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. Between January 2008 and December 2012, a total of 357 cases of 345 patients (age 15-29years) 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 ± 2.0years. 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 ≥ 20years and coverage with polyglycolic acid sheets were associated with reduced risk factors for postoperative recurrence. 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.

Vicryl Mesh Coverage Reduced Recurrence After Bullectomy for Primary Spontaneous Pneumothorax

Although thoracoscopic stapled bullectomy is a standard procedure for primary spontaneous pneumothorax (PSP), the postoperative recurrence rate is high. We investigated whether using a Vicryl (Ethicon, Somerville, NJ) mesh to cover the staple line after bullectomy reduces the postoperative recurrence rate. Our single-blind, parallel-group, prospective, randomized controlled trial at 2 medical centers in Taiwan studied patients with PSP who were aged 15 to 50 years and required thoracoscopic bullectomy. On the day of operation, patients were randomly assigned (1:1) to receive Vicryl mesh (mesh group) or not (control group) after thoracoscopic bullectomy with linear stapling and mechanical apical pleural abrasion. Randomization was achieved using computer-generated random numbers in sealed envelopes. Our primary end point was the pneumothorax recurrence rate within 1 year after the operation (clinicaltrials.gov number, NCT01848860.) RESULTS: Between June 2013 and March 2016, 102 patients were assigned to the mesh group and 102 to the control group. Within 1 year after operation, recurrent pneumothorax was diagnosed in 3 patients (2.9%) in the mesh group compared with 16 (15.7%) in the control group (P= .005). The short-term postoperative results and hospitalization duration were comparable between the groups. For thoracoscopic bullectomy with linear stapling and mechanical apical pleural abrasion, the use of a Vicryl mesh to cover the staple line is effective for reducing the postoperative recurrence of pneumothorax. Vicryl mesh coverage can be considered an optimal adjunct to the standard surgical procedure for PSP.

Risk factors for recurrence of primary spontaneous pneumothorax after thoracoscopic surgery.

Recurrence of pneumothorax after thoracoscopic surgery is a concerning issue for thoracic surgeons. In this study, we aimed to determine the risk factors for recurrence of spontaneous pneumothorax after thoracoscopic surgery. A total of 192 patients with spontaneous pneumothorax aged <50 years who underwent thoracoscopic surgery from January 2010 to December 2016 were included in this study. Pre- and post-operative characteristics were obtained from medical records, and recurrent and non-recurrent cases were compared. Fourteen patients (7.3%) experienced pneumothorax recurrence. Pneumothorax recurrence was observed more frequently in patients aged <20 years (P=0.041) and those in whom bullae were not identified on preoperative computed tomography (CT) (P=0.049). The use of polyglycolic acid (PGA) sheets during surgery significantly decreased the recurrence rate (P=0.031). A history of ipsilateral pneumothorax before surgery was a significant risk factor for recurrence after thoracoscopic surgery (P=0.001). In the multivariate analysis, a history of ipsilateral pneumothorax and identification of bullae on CT were identified as significant risk factors for recurrence. A history of ipsilateral pneumothorax, and inability to identify bullae on preoperative CT were risk factors for postoperative recurrence of pneumothorax.

A total pleural covering of absorbable cellulose mesh prevents pneumothorax recurrence in patients with Birt-Hogg-Dub\xe9 syndrome

BackgroundBirt-Hogg-Dubé syndrome (BHDS) is a recently recognized inherited multiple cystic lung disease causing recurrent pneumothoraces. Similarly to the lesions in patients with lymphangioleiomyomatosis (LAM), the pulmonary cysts are innumerable and widely dispersed and cannot all be removed. We recently described a total pleural covering (TPC) that covers the entire visceral pleura with oxidized regenerated cellulose (ORC) mesh. TPC successfully prevented the recurrence of pneumothorax in LAM patients. The purpose of this study was to evaluate the effect of an ORC pleural covering on pneumothorax recurrence in BHDS patients.ResultsThis retrospective study enrolled a total of 81 pneumothorax patients with the diagnosis of BHDS who underwent 90 covering surgeries from January 2010 to August 2017 at Tamagawa Hospital. During the first half of the study period, a lower pleural covering (LPC) which covered the affected area with ORC mesh was mainly used to treat 38 pneumothoraces. During the second half of the study period, TPC was primarily performed for 52 pneumothoraces. All the thoracoscopic surgeries were successfully performed without serious complications (≥ Clavien-Dindo grade III). The median follow-up periods after LPC/TPC were 66/34 months, respectively. Pneumothorax recurrence rates after LPC at 2.5/5/7.5 years postoperatively were 5.4/12/42%, respectively; none of the patients who had underwent TPC developed postoperative pneumothorax recurrence (P = 0.032).ConclusionsTPC might be an effective option for surgical treatment of intractable pneumothorax in patients with BHDS.

Influence of lung resection volume on risk of primary spontaneous pneumothorax recurrence.

Thoracoscopic stapled bullectomy is a popular procedure for the treatment of primary spontaneous pneumothorax (PSP) that has a relatively high postoperative recurrence rate. One reason for PSP recurrence is the formation of a new bulla around the staple line. We hypothesized that different resected specimen volumes might cause differences in staple line tension. In this study, we analyzed the relationship between postoperative pneumothorax recurrence and resected lung volume. Between April, 2009 and December 2013, 360 cases which underwent video-assisted thoracoscopic surgery (VATS) for PSP were selected. Recurrence after VATS was examined by electronic medical records and telephone survey. Resected volume and vertical area of specimen were calculated with the size of pathologic specimen. A mean follow up period was 44.5±24.4 months and recurrence rate was 11.1% (40/360). Large volume of resected specimen (≥16 cm3) (P=0.027 by the log-rank test) and larger vertical area of resected specimen (≥2.0 cm2) (P=0.003 by the log-rank test) showed significantly high recurrence rate. Cox regression analysis demonstrated that age [hazard ratio (HR), 0.083, P=0.006], vertical section area of resected specimen (HR, 1.239, P=0.020) and volume of resected pathology specimen (HR, 1.039, P=0.009) were independent risk factors of recurrence. Bulky resection during VATS for PSP increases the risk of recurrence. Large volume and vertical area of resected specimen are associated with greater tension in stapling line. Avoidance of wide resection and the firing of stapler after full collapse of lung are recommended for reducing the pneumothorax recurrence after VATS.

Risk factors for postoperative recurrence of spontaneous pneumothorax treated by video-assisted thoracoscopic surgery

Over the past two decades, video-assisted thoracoscopic blebectomy and pleurodesis have been used as a safe and reliable option for treatment of spontaneous pneumothorax. The aim of this study is to evaluate the long-term outcome of video-assisted thoracoscopic surgery (VATS) treatment of spontaneous pneumothorax in young patients, and to identify risk factors for postoperative recurrence. We retrospectively analysed the outcome of VATS treatment of spontaneous pneumothorax in our institution in 150 consecutive young patients (age ≤ 40 years) in the years 1997-2010. Treatment consisted of stapling blebectomy and partial parietal pleurectomy. After excluding 16 patients lost to follow-up, in 134 cases [110 men, 24 women; mean age, 25 ± 7 standard deviation years; median follow-up, 79 months (range: 36-187 months)], we evaluated postoperative complications, focusing on pneumothorax recurrence, thoracic dysaesthesia and chronic chest pain. Risk factors for postoperative pneumothorax recurrence were analysed by logistic regression. Of 134 treated patients, 3 (2.2%) required early reoperation (2 for bleeding; 1 for persistent air leaks). Postoperative (90-day) mortality was nil. Ipsilateral pneumothorax recurred in 8 cases (6.0%) [median time of recurrence, 43 months (range: 1-71 months)]. At univariate analysis, the recurrence rate was significantly higher in women (4/24) than in men (4/110; P = 0.026) and in patients with >7-day postoperative air leaks (P = 0.021). Multivariate analysis confirmed that pneumothorax recurrence correlated independently with prolonged air leaks (P = 0.037) and with female gender (P = 0.045). Chronic chest wall dysaesthesia was reported by 13 patients (9.7%). In 3 patients, (2.2%) chronic thoracic pain (analogical score >4) was recorded, but only 1 patient required analgesics more than once a month. VATS blebectomy and parietal pleurectomy is a safe procedure for treatment of spontaneous pneumothorax in young patients, with a 6% long-term recurrence rate in our experience. Postoperative recurrence significantly correlates with female gender and with prolonged air leakage after surgery.

Staple Line Coverage with a Polyglycolic Acid Sheet Plus Pleural Abrasion by Thoracoscopic Surgery for Primary Spontaneous Pneumothorax in Young Patients

We investigated surgical results of staple line coverage with a polyglycolic acid sheet plus pleural abrasion by thoracoscopic surgery for treating primary spontaneous pneumothorax in young patients. Forty-seven patients younger than 40 years underwent 48 thoracoscopic surgical procedures for spontaneous pneumothorax at the Division of Thoracic Surgery, Department of Surgery, Nippon Medical School, from May 2007 through August 2010. All patients underwent thoracoscopic bullectomy with stapling devices and pleural abrasion performed with a gauze sponge held by forceps until the pleura became petechial. Finally, the staple line was covered with a polyglycolic acid sheet (10 × 10 cm). No fibrin glue was used. We investigated both short-time results after surgery and the postoperative recurrence of pneumothorax. There was no operative mortality or morbidity, such as air leakage from staple lines or hemorrhage due to pleural abrasion. Pneumothorax recurred after surgery in 3 cases. In 2 cases, neither re-operation nor tube thoracostomy was necessary because intrapleural adhesions allowed only partial collapse of the lung. One patient underwent re-operation for an overlooked bulla facing the diaphragm in left lower lobe of the lung 2 days after the first operation. The rate of freedom from pneumothorax 4 years after surgery was 94%. Staple line coverage with a polyglycolic acid sheet plus pleural abrasion by thoracoscopic surgery is a useful method for preventing morbidity and the postoperative recurrence of pneumothorax.

Surgery for secondary spontaneous pneumothorax

Secondary spontaneous pneumothorax (SSP) can occur in patients who are suffering from diffuse lung disease. The main cause of SSP is chronic obstructive pulmonary disease (COPD). In contrast to primary spontaneous pneumothorax, SSP is a potentially life-threatening condition because patients with SSP also have limited cardiopulmonary reserve. Prompt diagnosis and treatment of SSP are mandatory. In this review, thoracoscopy, a less invasive surgical treatment for SSP, is discussed from the viewpoint of postoperative morbidity, mortality, and recurrence of SSP. A meta-analysis showed that postoperative recurrence of pneumothorax is more frequently observed following thoracoscopy than following open thoracotomy. Recent studies on thoracoscopic surgery for SSP have shown that the rate of postoperative morbidity is still high (15-27.7%) and thoracoscopy is sometimes replaced with open thoracotomy because of dense pleural adhesion or inability to maintain one-lung ventilation during surgery. However, many thoracic surgeons prefer to perform thoracoscopic surgery for SSP because it is less invasive than open thoracotomy. Techniques for bullectomy and pleurodesis are currently being adapted to decrease the recurrence rate of pneumothorax. Thoracoscopic surgery for the treatment of SSP should be less invasive to reduce postoperative morbidity, and it should also be more effective to reduce the recurrence of pneumothorax.

An apical symphysial technique using a wide absorbable mesh placed on the apex for primary spontaneous pneumothorax

The outcome of thoracoscopic bullectomy for primary spontaneous pneumothorax (PSP) is not satisfactory. To reduce postoperative pneumothorax recurrence after thoracoscopic bullectomy, an effective and easy surgical method is required. We tried a new method using an absorbable mesh that covered the whole apical visceral pleura. A total of 157 sides of 143 patients who underwent stapled bullectomy under thoracoscopy for PSP were reviewed retrospectively. In the apical covering group (group A), a 15 x 15-cm(2) absorbable mesh sheet was placed on the apical visceral pleura with fibrin glue. Patients in group B underwent bullectomy alone. Cumulative postoperative recurrence was compared between the groups. Recurrent cases in group A were examined clinicopathologically. Group A had 111 cases and group B had 46. There was no operative mortality. Postoperative recurrence occurred in 15 of 157 cases (9.6%): 4 in group A and 11 in group B. The cumulative postoperative 5-year recurrence rate was 3.6% in group A and 23.9% in group B (log-rank test, p = 0.013). In group A, local adhesion was seen at the apical pleurae, and inflammatory changes with foreign body giant cells were seen at the pleura covered with the mesh. Placement of a wide absorbable mesh with fibrin glue at the apical visceral pleura significantly reduced postoperative recurrence after thoracoscopic bullectomy for PSP. The mesh was thought to act as a foreign body on the pleura and induce local inflammatory adhesion between the apical pleurae after bullectomy. This was an easy and effective symphysial procedure.

Postoperative Recurrences of Pneumothorax in Video-assisted Thoracoscopic Surgery for Primary Spontaneous Pneumothorax in Young Patients

The postoperative recurrence rate of pneumothorax tends to be higher with thoracoscopic bullectomy than with conventional plication of bullae by axillary thoracotomy or posterolateral thoracotomy. We analyzed the risk factors for postoperative recurrence of pneumothorax in young patients treated with thoracoscopic bullectomy alone for primary spontaneous pneumothorax. Univariate and multivariate analyses were performed of a consecutive series of 53 patients (62 sides) who underwent video-assisted thoracoscopic bullectomy from March 1994 through March 2004. Pneumothorax recurred after 10 operations (16.1%). Eighty percent of postoperative pneumothorax recurrences developed within 5 months after surgery. Univariate analysis of postoperative pneumothorax recurrences revealed significant risk factors to be the early period of video-assisted thoracoscopic surgery (VATS) experience for primary spontaneous pneumothorax and a low number of pack-years (p<0.05 and p<0.05, respectively). Multivariate logistic regression test revealed that the early period of VATS experience was the single significant risk factor (odds ratio, 0.275; 95% confidence interval, 0.095-0.797; p value, 0.0174). Seventy percent of postoperative pneumothorax recurrences probably developed because of overlooked bullae and incomplete resection of bullae in the early period of VATS experience. Close observation of the pleural cavity to find bullae and bullectomy with a sufficient margin of normal pleurae and pulmonary parenchyma prevented postoperative pneumothorax recurrences significantly in the middle and recent periods. Close observation of the pleural cavity to find bullae and bullectomy with a sufficient margin of normal pleurae and pulmonary parenchyma are important measures for preventing postoperative recurrence of pneumothorax.

Staple Line Reinforcement with Fleece-Coated Fibrin Glue (TachoComb) After Thoracoscopic Bullectomy for the Treatment of Spontaneous Pneumothorax

We investigated the cause of pneumothorax recurrence after thoracoscopic surgery and the effectiveness of staple line reinforcement with fleece-coated fibrin glue (TachoComb) in the prevention of postoperative pneumothorax recurrence. From April 3, 1992 to the end of December 2005, thoracoscopic bullectomy was performed on 499 patients of primary spontaneous pneumothorax. The causes of recurrence were investigated on 39 patients on the basis of surgical observations, preoperative chest computed tomography, and so on. The most common cause was new bulla formation (37 cases), 19 of which were apparently related to the staple line (within 1 cm of the staple lines) and 15 of which were not related to the staple line. After 2000, we stopped using forceps to grasp lungs and we have reinforced the staple line by applying fleece-coated fibrin glue. The staple line reinforced with fleece-coated fibrin glue, or sprayed with fibrin glue solution and the untreated group (bullectomy only with staples) were compared, and the recurrence rates were 1.22%, 7.25%, and 10.00%, respectively (P = 0.0006021). The recurrence rate after thoracoscopic bullectomy with fleece-coated fibrin glue was significantly lowered and we consider this procedure to be the treatment of choice for the management of spontaneous pneumothorax.

内視鏡下手術 自然気胸に対する胸腔鏡下手術

Recent advances in optical and endoscopic instruments for surgery have made it possible to perform operations for spontaneous pneumothorax under video-assisted thoracic conditions (VATS), and now VATS is the first choice of operating methods for the pneumothorax. VATS has several advantages such as less surgical stress, and VATS use for spontaneous pneumothorax is likely to increase in the future. A major problem of VATS for pneumothorax, however, is that the incidence of postoperative recurrence of pneumothorax with VATS is higher than with thoracotomy. The causes of such recurrences are the failure to seek other bullae with video-assisted thoracoscopy, the inadequate firing of the endostaplers, and the new development of bullae from damage to the lung owing to the use of the endostapler or endoforceps. In order to decrease this high incidence of recurrence, preoperative investigations of bullae by chest CT scan, administering an endostapler to a normal lung area at the base of the bullae, and treating the lung gently with endoforceps are all important. The use of VATS for pneumothorax is just beginning and will develop greatly if these precautions are taken.

Spontaneous pneumothorax

Review of a large group of patients treated for spontaneous pneumothorax has revealed a progressively higher incidence of recurrence in the three periods studied, covering a span of seventeen years. During this time the immediate management of this entity has changed from simple bedrest plus occasional thoracentesis to the routine use of closed thoracostomy with water-seal suction drainage. Definite indications for operation have become established and include the following: (1) failure of prompt and complete re-expansion after closed thoracostomy; (2) one or more ipsilateral recurrences; (3) single recurrence with bilateral apical blebs; (4) simultaneous bilateral pneumothorax; (5) asynchronous bilateral pneumothorax; (6) single episode with apical lung cyst; (7) continued intrapleural bleeding. The operative procedure which is employed consists of anterolateral thoracotomy, apical wedge excision or over sewing of blebs, and the production of pleural symphysis by talc poudrage and pleural abrasion. There has been no postoperative recurrence of pneumothorax on the operated side.