Background Video-assisted thoracic surgery (VATS) is an increasingly common treatment for recurrent or persistent primary spontaneous pneumothorax (PSP). Surgery usually involves a diffuse treatment of the pleura and possible targeted surgical techniques on areas of bullous disease. There is no robust evidence to guide the use of specific surgical techniques. The purpose of this large observational cohort study was to examine the recurrence rates associated with VATS and identify predictors of outcome.
Methods Patients undergoing VATS for PSP at Carlo Forlanini hospital in Rome between January 2000 and December 2012 were prospectively collected. All patients underwent talc poudrage. Targeted surgical techniques were selected based on the presence of air leak and Vanderschueren stage. Patients had regular clinical and radiological follow-up for a minimum of 2 years. Surgical details, demographics and smoking histories were collected at baseline and data on duration of hospital stay, complications and recurrence rates were collated.
Results 1415 patients underwent VATS for PSP during the trial period. The majority of patients were male (76.2%). Median age was 25.3 years (IQR 21.0–29.4). The majority of patients underwent surgery due to recurrent pneumothorax (92.2%). Median length of stay was 5 days (IQR 5–6). 47 patients had incomplete follow up in December 2014 and so complete recurrence data is available for 1368 patients.
VATS had a low complication rate of 2%, the majority of which was prolonged air leak (1.7%). Recurrent pneumothorax occurred in 26 patients (1.9%) over a median follow up of 8.5 years. Recurrence rates were significantly higher in current smokers at the time of surgery (24/573–4.2%) than in non-smokers (2/796–0.25%) p < 0.001. Bullae suturing (3.9%) and ligation (15%) were associated with statistically significant higher rates of recurrence compared with poudrage alone when controlled for smoking status and Vanderschueren stage.
Conclusions The marked difference in recurrence rates between smokers and non-smokers suggests that this factor is of key importance in predicting recurrence risk after VATS. This study demonstrates a low incidence of recurrence for patients undergoing VATS for PSP. Bullae ligation and bullae suturing appear to be associated with a higher risk of recurrence.