Paradigm shift in surgical approaches to spontaneous pneumothorax: VATS
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* C S H Ng
* S Wan
* A P C Yim

The recently published BTS guidelines on the management of spontaneous pneumothorax by Henry *et al*1 have stimulated some discussion among our respiratory physicians and thoracic surgeons. We found it interesting that the authors quoted a pneumothorax recurrence rate of 5–10% after video assisted thoracoscopic surgery (VATS). Numerous large series from around the world have recently reported recurrence rates of primary spontaneous pneumothorax following VATS bullectomy combined with surgical pleurodesis to be in the range of 1.7–5.7%.2,3 Although the recurrence rates following VATS may be marginally higher than the open procedure, the benefit to the patient of a shorter postoperative hospital stay, less postoperative pain, and better pulmonary gas exchange in the postoperative period should be balanced against this. Furthermore, we found that patients who undergo VATS have significantly less shoulder dysfunction and pain medication requirements in the early postoperative period than after posterolateral thoracotomy.4 Whether VATS can be “established as being superior to thoracotomy” will in part be decided by our patients and become clearer with future trials.

With the lowered morbidity and proven safety of VATS, even for elderly and paediatric patients,2 the old surgical algorithms based on the morbidity of thoracotomy should be re-evaluated.5 We feel there are two additional conditions that warrant inclusion in the list for “accepted indication for operative intervention”. Firstly, patients presenting with the life threatening condition of tension pneumothorax, even for the first time, should be considered for VATS because of the potential grave consequences of its recurrence. Secondly, the presence of radiologically demonstrated huge bullae associated with spontaneous pneumothorax should be an indication for VATS because of the increased risk of recurrence. In addition, the huge bullae may continue to expand and impair lung function by causing compression of adjacent healthy lung tissue, and can be a manifestation of lung carcinoma or a focus for recurrent infection.2,6

## References

1.  **Henry M**, Arnold T, Harvey J. BTS guidelines for the management of spontaneous pneumothorax. Thorax2003;58(Suppl II):ii39–52.
    
    [Abstract/FREE Full Text](http://thorax.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6OToidGhvcmF4am5sIjtzOjU6InJlc2lkIjtzOjE1OiI1OC9zdXBwbF8yL2lpMzkiO3M6NDoiYXRvbSI7czoyNjoiL3Rob3JheGpubC81OS80LzM1Ny4xLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

2.  **Ng CSH**, Wan S, Lee TW, *et al.* Video-assisted thoracic surgery in spontaneous pneumothorax. Can Respir J2002;9:122–7.
    
    [PubMed](http://thorax.bmj.com/lookup/external-ref?access_num=11972165&link_type=MED&atom=%2Fthoraxjnl%2F59%2F4%2F357.1.atom) 

3.  **Yim APC**, Ng CSH. Thoracoscopic management of spontaneous pneumothorax. Curr Opin Pulm Med2001;7:210–4.
    
    [CrossRef](http://thorax.bmj.com/lookup/external-ref?access_num=10.1097/00063198-200107000-00008&link_type=DOI) 
    
    [PubMed](http://thorax.bmj.com/lookup/external-ref?access_num=11470976&link_type=MED&atom=%2Fthoraxjnl%2F59%2F4%2F357.1.atom) 

4.  **Li WWL**, Lee RLM, Lee TW, *et al.* The impact of thoracic surgical access on early shoulder function: video-assisted thoracic surgery versus posterolateral thoracotomy. Eur J Cardiothorac Surg2003;23:390–6.
    
    [Abstract/FREE Full Text](http://thorax.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiZWpjdHN1cmciO3M6NToicmVzaWQiO3M6ODoiMjMvMy8zOTAiO3M6NDoiYXRvbSI7czoyNjoiL3Rob3JheGpubC81OS80LzM1Ny4xLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

5.  **Yim APC**. Video assisted thoracoscopic surgery (VATS) in Asia: its impact and implications. Aust NZ J Med1997;27:156–9.
    
    [PubMed](http://thorax.bmj.com/lookup/external-ref?access_num=9145178&link_type=MED&atom=%2Fthoraxjnl%2F59%2F4%2F357.1.atom) 
    
    [Web of Science](http://thorax.bmj.com/lookup/external-ref?access_num=A1997WX57900003&link_type=ISI) 

6.  **Ng CSH**, Sihoe ADL, Wan S, *et al.* Giant pulmonary bulla. Can Respir J2001;8:369–71.
    
    [PubMed](http://thorax.bmj.com/lookup/external-ref?access_num=11694917&link_type=MED&atom=%2Fthoraxjnl%2F59%2F4%2F357.1.atom) 

# Authors’ reply {#article-title-2}

*   spontaneous pneumothorax
*   video assisted thoracoscopic surgery VATS
*   BTS

We thank Dr Ng and colleagues for their comments on the recently published guidelines on the management of spontaneous pneumothorax.1 Dr Ng points out that recurrence rates for pneumothorax after VATS preventative procedures were lower than those quoted in the guidelines. It should be pointed out that, in the multiple drafts of this document, it was recognised that recurrence rates after VATS were falling and that further improvements in these figures were likely as operator experience improved. This was recognised within the guidelines. It is fully expected that, as experience and provision of services improve, VATS will replace open thoracotomy for treatment of recurrent pneumothoraces.

In response to Dr Ng’s second point regarding surgical treatment of tension pneumothoraces and hugh bullae, the guidelines obviously could not take into account every possible clinical scenario. As far as we are aware, there is no evidence to suggest that tension pneumothoraces are more likely to recur than “non-tension” spontaneous pneumothoraces. This does not mean, of course, that an individual physician should not decide that the clinical risk in an individual patient—either from rupture of a huge bulla or recurrence of a tension pneumothorax—should not warrant surgical intervention.

## Reference

1.  **Henry MT**, Arnold A, Harvey J. BTS guidelines for the management of spontaneous pneumothorax. Thorax2003;58(Suppl II):ii39–52.
    
    [Abstract/FREE Full Text](http://thorax.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6OToidGhvcmF4am5sIjtzOjU6InJlc2lkIjtzOjE1OiI1OC9zdXBwbF8yL2lpMzkiO3M6NDoiYXRvbSI7czoyNjoiL3Rob3JheGpubC81OS80LzM1Ny4xLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==)