Does a gender have something to do with clinical pictures of primary spontaneous pneumothorax?

OBJECTIVE: Primary spontaneous pneumothorax is relatively rarer in women than in men. In addition, women develop secondary spontaneous pneumothorax, such as lymphangioleiomyomatosis, which is rare and difficult to diagnose. Therefore, the clinical characteristics of primary spontaneous pneumothorax in women remain unknown presently. We compared the clinical characteristics of primary spontaneous pneumothorax between the two sexes at two pneumothorax centers. METHODS: Between January 2015 and July 2019, we retrospectively evaluated 627 cases (106 women and 521 men) who underwent first video-assisted thoracoscopic surgery for primary spontaneous pneumothorax and extracted the medical backgrounds and postoperative recurrence between the sexes. Univariate and multivariate analysis was used to examine the effect of sexual specificity on postoperative recurrence. RESULTS: Among women and men with PSP, the mean ages were 27.8 ± 10.7 and 24.3 ± 10.0 years, respectively; their mean heights were 162.0 ± 5.9 and 173.3 ± 6.1 cm, respectively. These differences were statistically significant. Three women (2.8%) and 54 men (10.4%) developed postoperative recurrence, which showed significant difference on Kaplan-Meier analysis (p = 0.027). Univariate and multivariate analysis showed the factors; women (p = 0.045, hazard ratio: 0.289 [95% confidence interval 0.086-0.973]) and smoker (p = 0.035, hazard ratio: 0.269 [95% confidence interval 0.079-0.909]) had the preventing factor for postoperative recurrence, respectively. CONCLUSIONS: Women with PSP had lower postoperative recurrence rate than men. Although we could not reveal why women had lower postoperative recurrence rates than men in this study, the sexual difference such as hormonal cycle, development of body structure possibly affects the clinical characteristics of women with primary spontaneous pneumothorax.

The clinical characteristics and surgical results of smoking-related young pneumothorax.

OBJECTIVE: Primary spontaneous pneumothorax is a common disease that develops in relatively young healthy patients. Although smoking is generally believed to have a negative effect on the lungs, some authors reported that smokers with primary spontaneous pneumothorax had significantly lower postoperative recurrence rates than nonsmokers. This unexpected result suggests that primary spontaneous pneumothorax is classified into two categories: smoking-related young pneumothorax and residual primary spontaneous pneumothorax. We compared these two categories to determine their characteristics and corresponding surgical results. METHODS: Between January 2009 and December 2018, we enrolled 267 consecutive cases that underwent first surgery for primary spontaneous pneumothorax in our hospital. A total of 252 eligible cases (211 residual primary spontaneous pneumothorax and 41 smoking-related young pneumothorax) underwent evaluation. Smoking-related young pneumothorax cases were defined as cases with characteristic HRCT findings and smoking habit. RESULTS: The mean ages for the residual primary spontaneous pneumothorax and smoking-related young pneumothorax groups were 25.9 ± 13.1 and 30.5 ± 6.9 years, respectively. The groups included 186 (88.2%) and 41 (100.0%) men, and the mean body mass indices were 19.1 ± 2.2 and 20.0 ± 1.9, respectively. Fifty-nine (28.0%) and 41 (100.0%) subjects were smokers, and there were 43 (20.4%) and 1 (2.4%) cases of postoperative recurrence, respectively. These results were significantly different between the two groups. CONCLUSIONS: Individuals with smoking-related young pneumothorax were older, predominantly men, and had higher body mass index and significantly lower postoperative recurrence rates than those with residual primary spontaneous pneumothorax.

Optimal margin distance of bullectomy for primary spontaneous pneumothorax reduces postoperative recurrence.

BACKGROUND: For primary spontaneous pneumothorax, bullectomy using autosutures is the standard procedure. Despite performing various methods for preventing postoperative recurrence, it remains relatively high. Although considering the margin distance of bullectomy is important, no argument has been discussed for the optical margin distance until now. Hence, we evaluated the optimal margin distance for bullectomy of spontaneous pneumothorax, bullectomy to reduce postoperative recurrence. METHODS: Between March 2015 and May 2018, 91 eligible candidates from 142 cases, who underwent video-assisted thoracoscopic bullectomy for spontaneous pneumothorax, bullectomy, were evaluated. We analysed the factors preventing postoperative recurrence, including the margin distance using the inverse-probability of treatment weighted method by propensity score was used to adjust for heterogeneous patient backgrounds. RESULTS: The patients' median age was 20 years (range, 14-86 years). Postoperative recurrences occurred in 8 cases (8.8%). The margin distance was 9.1±5.0 mm. The cut-off point of the margin distance was defined as 5.0 mm. The inverse-probability of treatment weighted method indicated that a margin distance ≥5.0 mm significantly prevented postoperative recurrence (P=0.0076, hazard ratio =0.18). CONCLUSIONS: This study suggests that a margin distance of ≥5.0 mm for bullectomy of PSP can reduce postoperative recurrence.

Contralateral bulla neogenesis associated with postoperative recurrences of primary spontaneous pneumothorax in young patients.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) is considered an acceptable treatment for recurrent primary spontaneous pneumothorax (PSP). However, recent reports have described a high postoperative recurrence rate in young patients with PSP. We hypothesized that ineffective VATS may have been performed for these patients (aged <25 years). We evaluated the factors preventing postoperative recurrence in young PSP patients in order to identify patients with effective surgery. METHODS: Between April 2009 and December 2018, we retrospectively evaluated 92 patients aged <25 years who underwent first VATS bullectomy for PSP. Factors such as gender, smoking habit, history of contralateral PSP, family history, body mass index (BMI), and contralateral bulla neogenesis on high-resolution computed tomography were evaluated. RESULTS: The mean BMI was 18.8±1.8. Contralateral bulla neogenesis was present in 31 patients (33.7%). The median period of observation for postoperative recurrence was 401.5 days. Thirty cases (32.6%) developed postoperative recurrence. Univariate and multivariable analyses showed that a BMI ≥18.0 and no contralateral bulla neogenesis were significant factors preventing postoperative recurrence (P=0.018, hazard ratio: 0.41 and P=0.0046, hazard ratio: 0.25, respectively). CONCLUSIONS: Although the patients aged <25 years have a high rate of postoperative recurrence, the patients with BMI ≥18.0 and no contralateral bulla neogenesis have a significantly lower rate of postoperative recurrence rate.

Natural history of bulla neogenesis for primary spontaneous pneumothorax: a propensity score analysis.

OBJECTIVE: For patients with recurrent primary spontaneous pneumothorax, surgery has been thought to be an acceptable treatment. However, even if bulla is completely resected, postoperative recurrence is relatively common due to bulla neogenesis. Bulla neogenesis seems to develop naturally in younger patients compared with the elderly, as theorized till date. If the complete development of bulla neogenesis is confirmed, surgical resection can be performed as the radical treatment. Then, we evaluated the relationship between bulla neogenesis and age. METHODS: Between February 2009 and July 2018, we consecutively enrolled 276 patients who underwent primary bullectomy for primary spontaneous pneumothorax in our hospital. Finally, high-resolution computed tomography findings/observations of 155 eligible patients were evaluated retrospectively. The relationship between bulla neogenesis and age was evaluated using univariate and multivariate analyses and an inverse probability of treatment-weighted method using the propensity score. RESULTS: The study included 58 patients aged < 20 years and 97 aged ≥ 20 years. Bulla neogenesis was present in 34 patients (21.9%). Bulla neogenesis developed significantly at age < 20 compared with age ≥ 20 (44.8 vs. 8.2%). Univariate and multivariate analyses showed that age < 20 years was a significant factor associated with bulla neogenesis (P < 0.001 and P = 0.018, respectively). The inverse probability of treatment-weighted method showed that age < 20 years was a significant factor associated with bulla neogenesis (P = 0.0057, hazard ratio 4.79). CONCLUSIONS: Surgical treatment may be delayed in young patients (age < 20 years), because bulla neogenesis is not completely developed by this time for primary spontaneous pneumothorax.

Pleural Coating by 50% Glucose Solution Reduces Postoperative Recurrence of Spontaneous Pneumothorax.

BACKGROUND: Video-assisted thoracoscopic surgery is the standard procedure for treatment of spontaneous pneumothorax. However, postoperative recurrence is relatively common even if an absorbable covering sheet is used for reinforcement of the visceral pleura. Injection of a high concentration glucose solution to the thoracic cavity was recently reported to be effective in stopping postoperative air leakage or as a prophylactic procedure to prevent postoperative recurrence of spontaneous pneumothorax. Therefore, we used 50 mL of a 50% glucose solution for pleural coating (GPC) on an absorbable sheet intraoperatively to prevent postoperative recurrence of spontaneous pneumothorax. This is a retrospective study, and patient backgrounds are heterogeneous. We evaluated the feasibility of GPC using propensity scores to adjust for heterogeneity in their backgrounds. METHODS: Between January 2010 and December 2017, 376 patients who underwent video-assisted thoracoscopic surgery, with or without GPC, were evaluated. The GPC group consisted of 106 patients, and the non-GPC group consisted of 270. We analyzed the factors preventing postoperative recurrence of spontaneous pneumothorax by univariate analysis and Cox regression analysis with or without propensity score matching. RESULTS: Univariate analysis revealed age of 25 or older, smoking habit, no history of an ipsilateral operation, and GPC were significant factors preventing postoperative recurrence. GPC significantly prevented postoperative recurrence as shown by Cox regression analysis with propensity score matching (hazard ratio, 0.15; p = 0.014) and the inverse-probability of treatment weighted method (hazard ratio, 0.23; p = 0.0038). CONCLUSIONS: Intraoperative GPC significantly reduced the postoperative recurrence rate of spontaneous pneumothorax.

[Injection of High Concentration Glucose Solution for Pleural Coating Reduces Postoperative Recurrence of Spontaneous Pneumothorax;A Short-term Retrospective Study].

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) is the standard treatment for patients with spontaneous pneumothorax (SP). However, postoperative recurrence is not infrequent even with an absorbable covering sheet used to reinforce the visceral pleura. Recent reports suggest that intraoperative injection of a highly concentrated glucose solution into the thoracic cavity provides effective prophylaxis against postoperative SP recurrence. Since September 2015, we have been injecting 50 ml of 50 % glucose solution intraoperatively for pleural coating (GPC) around an absorbable sheet to prevent postoperative SP recurrence. METHODS: We evaluated 340 patients who underwent VATS between February 2011 and June 2017(88 patients:GPC group, 252:non-GPC group), and we retrospectively analyzed the efficacy of GPC in preventing postoperative SP recurrence. RESULTS: One year postoperative recurrence rates of GPC and non-GPC groups were 9.0 and 17.9%,respectively. The log-rank test revealed GPC as a significant factor in preventing postoperative recurrence (p=0.020). No severe adverse events occurred in either group. Minor postoperative complications, viz., high blood sugar, high volume of chest tube drainage occurred in the GPC group. CONCLUSION: Application of GPC is beneficial in reducing postoperative recurrence of SP.

Feasibility of single-incision thoracoscopic surgery using a modified chest wall pulley for primary spontaneous pneumothorax: a propensity score matching analysis.

PURPOSE: Recently, single-incision thoracoscopic surgery (SITS) has been recognized as a favorable treatment choice for primary spontaneous pneumothorax (PSP) compared with conventional three-port video-assisted thoracoscopic surgery (VATS). However, conventional SITS bullectomy often results in collisions with surgical devices. Therefore, we devised a method of SITS using a chest wall pulley for lung excision (PulLE) and modified PulLE (mPulLE) system, which substitutes threads to eliminate such collisions. We compared the mPulLE system with conventional procedures using propensity score matching (PSM) to adjust for patient backgrounds. METHODS: Using PSM, we evaluated the surgical results of 210 PSP patients who underwent VATS, including mPulLE (n = 23) and three-port VATS (n = 102), at our institution between January 2010 and August 2016. RESULTS: We selected 17 mPulLE cases and 17 three-port VATS. There were no marked differences between the groups in the patient backgrounds or surgical results. However, there was a significant difference between the mPulLE cases and the three-port VATS cases in the operative time (71.7 ± 15.7 vs. 85.9 ± 25.5 min, respectively, P = 0.0388) and the number of autosutures used (3.6 ± 1.2 vs. 4.5 ± 1.2, respectively, P = 0.0178). CONCLUSION: The surgical results of mPulLE in patients with PSP with multiple lesions were equivalent to those achieved with three-port VATS under the same conditions.

Modified Chest Wall Pulley for Lung Excision during Single-Incision Thoracoscopic Surgery for Primary Spontaneous Pneumothorax.

We reported the feasibility of single-incision thoracoscopic surgery bullectomy using a chest wall pulley for lung excision (PulLE) in patients with primary spontaneous pneumothorax (PSP). PulLE has many merits including comfort of manipulation, cosmetic advantages, etc., compared to other procedures. However, our method was utilized for relatively straightforward cases. The PulLE was contraindicated for PSPs with multiple or comprehensive bullae. Therefore, we developed the modified PulLE (mPulLE) to treat such cases in February 2015. Although one chest wall pulley is placed in the thoracic cavity for a PulLE, two are used for an mPulLE. Herein, we describe the mPulLE technique.

[Propensity-score-matched Comparison of Postoperative Pain Between Young and Elderly Patients Who Underwent Video-assisted Thoracoscopic Surgery for Spontaneous Pneumothorax].

Video-assisted thoracoscopic surgery (VATS) is the standard treatment for spontaneous pneumothorax(SP). Although VATS has decreased the postoperative pain in comparison with conventional thoracotomy, the procedure still often requires sufficient postoperative pain management especially for young patients, and the present study on the postoperative pain management focused on the age difference was designed. Using the numerical rating scale, we compared postoperative pain between the young group(36 patients) and the elderly group (36 patients) selected by propensity score matching in order to adjust for the patients' backgrounds. Although the young group had significantly stronger pain than the elderly group immediately after surgery(4.9±2.5 vs.3.2±2.4, p=0.002), it improved promptly. Moreover, the young group required significantly more frequent continuous infusions of opioids after surgery( p=0.001). In conclusion, it is considered that the postoperative pain management in the pneumothorax surgery should be customized according to the age.

Association between postoperative bulla neogenesis at the staple line and resected lung weight for primary spontaneous pneumothorax: a retrospective study using the inverse-probability of treatment weighted method in patients grouped according to age.

BACKGROUND: Bullectomy using autosutures is the standard procedure in patients with primary spontaneous pneumothorax (PSP). However, postoperative bulla neogenesis (POBN) along the staple line is relatively common and promotes PSP recurrence. We have previously reported the relationship between POBN and resected lung weight (LW). However, recently published data indicate that young patients with PSP have a high postoperative recurrence rate. Therefore, we evaluated the relationship between POBN and LW in PSP patients, subdivided according to age. METHODS: Between February 2011 and April 2016, 96 lung-resection sites in 67 patients who underwent bullectomy were evaluated. Patients were subdivided into two groups by age: Y group (<25 years, 56 sites) and O group (≥25 years, 40 sites). We used the inverse-probability of treatment weighted (IPTW) method to adjust for the heterogeneity in their backgrounds. POBN was diagnosed by computed tomography. RESULTS: Cox regression analysis for the O group indicated that LW ≥3.0 g was a significant risk factor for POBN (P=0.049). For the Y group, no association between lung weight and POBN was observed. CONCLUSIONS: A LW ≥3.0 g is a significant risk factor for POBN in individuals aged ≥25 years.

Novel paravertebral block during single-incision thoracoscopic surgery for primary spontaneous pneumothorax.

Recently, the use of paravertebral block (PVB) during thoracic surgery has been re-evaluated, as it is not inferior to epidural anaesthesia for postoperative pain control, and has been associated with fewer complications (e.g., hematoma of epidural, hypotension, urinary retention, postoperative nausea and vomiting). No reports have described intraoperative catheterization for PVB during single-incision thoracoscopic surgery (SITS) as distinct from thoracotomy or multi-ports video-assisted thoracoscopic surgery. We describe a case of SITS bullectomy using a chest wall pulley for lung excision to treat primary spontaneous pneumothorax and 25 catheterizations for PVB during SITS that have been performed since June 2013. Our novel technique is both easy and safe. It is ideal to combine PVB with SITS because both methods are less invasive.

Relationship between postoperative bulla neogenesis at the staple line and the resected lung volume in primary spontaneous pneumothorax.

PURPOSE: In patients with primary spontaneous pneumothorax (PSP), bullae are generally resected using autosutures under video-assisted thoracoscopic surgery (VATS). However, postoperative bulla neogenesis (POBN) along the staple line is not rare and is a factor promoting PSP recurrence. POBN is attributed to tension along the staple line, and we surmise that the resected lung volume affects this tension. Therefore, in this study, we retrospectively examined the relationship between POBN and the resected lung volume in patients who underwent surgical treatment of PSP. METHODS: Between February 2011 and May 2015, 70 lung resection sites in 56 PSP patients who underwent primary VATS at our hospital were evaluated. POBN was diagnosed on high-resolution computed tomography 1 year postoperatively in principle. RESULTS: POBN was detected at 26 of 70 (37.1 %) sites. On univariate analysis, lung weight ≥1.5 g, lung length ≥4.0 cm, resected site: apical, age <25 years old and non-smoking habit were identified as significant, and the POBN rates for cases with lung weight ≥1.5 g or lung length ≥4.0 cm were 47.9 % (P = 0.004) and 44.1 % (P < 0.001), respectively. On multivariate analysis, lung weight ≥1.5 g was only significant factor for POBN (P = 0.043). CONCLUSION: A resected lung weight ≥1.5 g was only significant risk factor of POBN in patients with PSP.

Single-incision thoracoscopic surgery using a chest wall pulley for lung excision in patients with primary spontaneous pneumothorax.

PURPOSE: The aim of the study was to evaluate the feasibility and compare the outcomes of single-incision thoracoscopic surgery using a chest wall pulley for lung excision (PulLE) vs. those of conventional video-assisted thoracic surgery (cVATS) in patients with primary spontaneous pneumothorax (PSP). METHODS: Sixty-nine patients who underwent PulLE (n = 34) or cVATS (n = 35) between January 2009 and December 2013 were enrolled in this study. PulLE was performed as follows. After making a 17- to 25-mm single incision in the 6th intercostal space (6ICS) at the median axillary line, the visceral pleura near the bulla was sutured for traction. The parietal pleura at 3ICS was then sutured from the thoracic cavity to serve as the chest wall pulley and a traction thread was passed through the pulley. By manipulating the traction thread, it was possible to move the lesion to an arbitrary site for excision. The postoperative scar was nearly invisible. RESULTS: The operative time, duration of postoperative drainage, and postoperative hospital stay were equivalent for PulLE vs. cVATS. There was no significant difference in postoperative recurrence rates. CONCLUSIONS: PulLE has cosmetic benefits over cVATS and is easy to perform. We believe our novel procedure has the potential to become the standard operative treatment for PSP.

[Evaluation of 2 ports video-assisted thoracoscopic surgery (VATS) using endo-close for primary spontaneous pneumothorax].

We aimed to assess the perioperative outcomes of 2 ports video-assisted thoracoscopic surgery(VATS) using Endo-Close (2 ports VATS) in patient for the primary spontaneous pneumothorax(PSP) compared to conventional 3 ports VATS in our hospital. 31 consecutive patients(11;2 ports VATS and 20;3 ports VATS) since 2009 were enrolled in this study. Endo-Close is a device that for pulling the anchoring thread by puncture 1.5 cm incision at the level of the 7th intercostal space( ICS) at the median axillary line( MAL) for camera port, a 1.5 cm incision at the level of the 4th ICS at the anterior axillary line for working port, and 2 mm puncture at the level of the 5th ICS at the MAL using the Endo-Close were placed for this procedure. Compared with 3 ports VATS, equivalent results were obtained by the present procedure;operation time(58.6±18.3 minutes vs 63.0±15.1 minutes, NS), duration of drainage after operation(1.0±0 days vs 1.3±0.5 days, NS), postoperative hospital stay(3.0±1.5 days vs 3.7±1.4 days, NS) significantly.Blood loss was minimal in both cases. In conclusion, 2 port VATS using Endo-Close proved to be feasible method in surgical treatment for PSP.

[Pleuroperitoneal communication with liver cirrhosis and chronic kidney disease needed hemodialysis successfully treated by video-assisted thoracoscopic surgery; report of a case].

A 59-year-old man treated with hemodialysis for liver cirhhosis and chronic kidney disease developed right pleural effusion and ascites. Ascites always decreased after thoracocentesis for pleural effusion. In spite of repeated treatment with chest tube drainage, massive pleural effusion reappeared. Under the diagnosis of pleuroperitoneal communication, surgical repair of the diaphragm by video assisted thoracoscopic surgery (VATS) were performed. Bulla and pin hole were found and they were resected and sutured. Surgery was safely and successfully accomplished though the patient had Child-Pugh B liver cirhhosis. Pleural effusion disappeared after surgery.