Primary pneumothorax: Should surgery be offered after the first episode?

Table 1 Summary of the key studies on surgical definitive management after a first episode of spontaneous pneumothorax

Ref.	No. of patients	Chest drain duration	Length of stay	Complications	Follow-up	Recurrence	Cost	Other
Schramel et al[64]	149 first episode PSP VATS: 70 Chest drain: 79	(Both first and recurrent episode included)	(Both first and recurrent episode included)	(Both first and recurrent episode included)	Chest drain: 96 ± 18 mo VATS: 29 ± 10 mo	1 yr: VATS (3%) < CD (19%) 2 yr: VATS (4%) < CD (22%)	VATS < Chest drain (total cost of 1 hospital stay + waiting time) Cost of treating recurrence: VATS similar to Chest drain	If waiting time (4.4 d for VATS) not considered, cost NS Chest drain patients, if have recurrence, were management by thoracotomy
Torresini et al[65]	70 Chest drain: 35 VATS: 35	VATS: 3.9 d Chest drain: 9 d	VATS: 6 d Chest drain: 12 d	Prolonged air leak > 6 d: VATS: 5.7% Chest drain: 11.4%	12 mo	VATS: 2.8% Chest drain: 22.8%	VATS: $1925 Chest drain: $2750 (also included cost of recurrence)	Secondary pneumothorax included Chest drain arm: 2 VATS arm: 4
Chou et al[67]	VATS: 51	2 d (54%)	3 d (54%)	No	38 mo	0	-
Margolis et al[68]	VATS: 156	-	2.4 ± 0.5 d	No	2-96 mo (median: 62 mo)	0	-	Talc poudrage for all patients intra-op
Sawada et al[23]	281 Chest drain: 181 Thoracotomy: 13 VATS: 87	-	Chest drain: 14.5 d Thoracotomy: 22.2 d VATS: 8.3 d (P < 0.001)	-	13-163 mo (mean: 78.3 mo) Not specified for first episode cases	Chest drain: 54.7% Thoracotomy: 7.7% VATS: 10.3% (P < 0.001) (Thoracotomy vs VATS: P = 0.61)	-	Length of stay analysis included both first and recurrent episodes
Chen et al[69]	52 Chest drain: 22 VATS: 30	-	VATS: 4.8 Chest drain: 6.1 (P = 0.034)	VATS: 6.7% Chest drain: 27.3% (P = 0.058)	3-38 mo (mean 16 mo)	VATS: 3.3% Chest drain: 22.7% (P = 0.038)	Total cost of 1 hospital stay VATS: $1273 Chest drain: $865	All patients had failed initial needle aspiration

VATS: Video assisted thoracic surgery; PSP: Primary spontaneous pneumothorax.