Treatment of pneumothorax: minimally or maximally invasive?

Treatment of spontaneous pneumothorax (SP) remains highly controversial. Rather different opinions exist, not only between pulmonary physicians and thoracic surgeons, but also on both sides of the Atlantic Ocean, and even between the UK and continental Europe. This controversial management is reflected in vivid discussions in respiratory and thoracic surgical meetings, as well as in different guidelines that have been published [ 1 , 2 ]. A fundamental problem remains that no large controlled randomized trials are currently available to demonstrate a clear advantage of one treatment over another.

In the present report, a large national database from France is analysed, comprising 7647 patients who were treated for primary or secondary SP between January 2005 and December 2012 [ 3 ]. Open thoracotomy was chosen as the access in 1004 patients (13%) and video-assisted thoracic surgery (VATS) or thoracoscopy in 6643 patients (87%). In the VATS group, there were more parenchymal resections, fewer mechanical pleurodesis procedures, fewer postoperative respiratory complications, fewer cases of postoperative pleural bleeding and shorter hospital stay. On the other hand, recurrence rate was 3.8% in the VATS group and 1.8% in the thoracotomy group.

The main strength of this large database is that it reflects current daily practice in the treatment of SP. Although no randomized data are available, some intriguing results are presented. Unfortunately, as can be expected from a large national database, data reporting is not complete, no uniform criteria were used for diagnosis and treatment, no distinction could be made between primary and secondary SP, which are quite different entities, and the choice between VATS and thoracotomy was made by the treating thoracic surgeon. Apparently, more extensive pleural procedures were performed in the thoracotomy group with pleurectomy or abrasion being applied in 93% of cases. In contrast, in the VATS group, chemical pleurodesis was a more frequent intervention. However, in the database, no distinction could be made between pleurectomy (apical, subtotal, total?) and pleural abrasion. Rather surprisingly, more parenchymal resections were performed in the VATS group for which no specific reason could be provided.

The mean hospital stay was quite long in this series, which were 9 days for the VATS and 16 days for the thoracotomy group. In view of current economical restrictions and cost containment measures, hospital stay has to be reduced in many European countries to get full reimbursement.

The recurrence rate after surgical treatment of SP equally remains a hotly debated and controversial topic. In the present study, recurrence was defined as a new pneumothorax requiring a chest tube or repeat surgery by VATS or thoracotomy. No details on any precise follow-up scheme, the proportion of symptomatic versus asymptomatic recurrences, or the number of patients lost to follow-up were provided. In this way, a substantial proportion of recurrences may not have been detected. In a recently published propensity score analysis from the same authors and resulting from the same database, the recurrence rate was higher in the VATS group regardless of the statistical method used [ 4 ]. In the present report, the overall recurrence rate was significantly higher in the VATS group (3.8%) compared with the thoracotomy group (1.8%). Does this reflect the approach only? Should thoracotomy be preferred to VATS in case of pneumothorax? However, more extensive pleural procedures were performed in the thoracotomy group which are probably more important in preventing recurrence than the incision itself. Chemical pleurodesis was applied more often in the VATS group, which may be considered suboptimal treatment, especially when larger bullae are present. The recurrence rate was found to be lower when these blebs or bullae are resected [ 5 ].

An intriguing finding in this study was that respiratory complications occurred more frequently on the right side when chemical pleurodesis was applied. Does this mean that talcage may be associated with an increase in respiratory complications, even when graded talc consisting of large particles is used? However, no specific data are available on the dosage used and the method of application (talc slurry or poudrage?).

To reconcile thoracic surgeons and pulmonary physicians, the European Respiratory Society (ERS) has established a task force consisting of seven dedicated pulmonary physicians and five thoracic surgeons to produce a comprehensive review of available evidence on diagnosis and treatment of SP [ 6 ]. For a first episode, the task force advises a treatment approach that is driven by symptoms rather than the size of the pneumothorax. In case of persistent or recurrent pneumothorax, pleurodesis by talc poudrage is considered to be safe, provided calibrated talc is used. The task force agreed that in case of visible rupture of the visceral pleura, the patient be referred for surgical treatment with resection of the leaking pulmonary parenchyma. Although it is acknowledged that the recurrence rate may be higher after VATS, this approach is preferred to thoracotomy as the latter represents a major incision in usually young patients. Recent developments include awake VATS and uniportal access to further reduce the invasiveness of the procedure [ 7 , 8 ].

As there are a lot of remaining controversial points, no definite recommendations can be made at the present time. The ERS task force concluded that more randomized controlled trials evaluating different therapeutic modalities are necessary, especially regarding the management of lung parenchyma, the specific pleurodesis technique and the efficiency of VATS compared with medical thoracoscopy [ 6 ]. In the meantime, every institution should determine its own diagnostic and therapeutic algorithm requiring cooperation between pulmonary physicians and thoracic surgeons. Precise follow-up data should be recorded to obtain more meaningful data on the treatment of this still elusive disorder.

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