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.

Table 2 Summary of the key studies on “next generation” video assisted thoracic surgery for pneumothorax

Ref.	No. of patients	Mean operating time	Mean blood loss	Mean chest drain duration	Mean post-operative length of stay	Post-op pain Scores	Follow-up	Recurrence	Residual wound discomfort	Wound satisfaction
Chen et al[37]	nVATS: 28 cVATS: 35	nVATS: 76.9 ± 25.5 cVATS: 83.6 ± 29.5 min (P = 0.34)	-	nVATS: 2.7 ± 1.7 d cVATS: 3.5 ± 2.0 d (P = 0.11)	nVATS: 4.3 ± 2.0 d cVATS: 5.1 ± 2.0 d (P = 0.106)	10-point VAS score on post-op Day 1, 2 and 3 nVATS similar to cVATS	Mean 8 mo	nVATS: 3.6% cVATS: 0 (P = 0.44)	nVATS < cVATS (P = 0.021)	nVATS > cVATS (P = 0.043)
Jutley et al[40]	uVATS: 16 cVATS: 19	-	-	uVATS: 4.6 ± 2 d cVATS: 3.9 ± 2.1 d (P = 0.35)	uVATS: 4.6 ± 2.1 d cVATS: 4.1 ± 1.0 d (P = 0.35)	4-point VAS Mean score: uVATS: 0.4 ± 0.5 cVATS: 0.8 ± 0.7 (P = 0.06) Maximum score: uVATS: 1.4 ± 0.9 cVATS: 2.6 ± 0.9 (P < 0.001)	uVATS: 9.4 ± 6.6 mo cVATS: 32.1 ± 9.9 mo	uVATS: 0 cVATS: 5.3%	uVATS: 14% cVATS: 58%	-
Salati et al[41]	uVATS: 28 cVATS: 23	uVATS: 72.3 min cVATS: 68.7 min (P = 0.67)	-	-	uVATS: 3.8 d cVATS: 4.9 d (P = 0.03)	-	uVATS: 13 mo cVATS: 39 mo	uVATS: 10% cVATS: 13% (P = 0.62)	uVATS: 35% cVATS: 94% (P < 0.001)	-
Chou et al[38]	nVATS: 106 cVATS: 89	nVATS: 82.36 ± 35.58 min cVATS: 99.78 ± 35.74 min (P = 0.008)	nVATS: 16.67 ± 25.90 mL cVATS: 24.36 ± 26.86 mL (P = 0.04)	-	nVATS: 4.85 ± 3.18 d cVATS: 5.14 ± 3.24 d (P = 0.5)	10-point VAS score nVATS: 4.80 ± 2.1 cVATS: 8 ± 1.7 (P < 0.001)	nVATS: 34.9 ± 12.5 mo cVATS: 69.2 ± 14.5 mo	nVATS: 2.8% cVATS: 1.1% (P = 0.4)	-	-
Yang et al[42]	uVATS: 27 cVATS: 13	uVATS: 74.6 ± 22.8 min cVATS: 72.4 ± 20.2 min (P = 0.77)	-	-	uVATS: 2.3 ± 0.7 d cVATS: 2.5 ± 0.8 d (P = 0.72)	10-point VAS score on post-op Day 0, 1, 2 uVATS similar to cVATS	uVATS: 2.1-7 mo cVATS: 2.3-8.2 (P = 0.13)	uVATS: 3.7% cVATS: 7.7% (P = 0.7)	uVATS: 33.3% cVATS: 76.9% (P = 0.01)	uVATS: 70.4% cVATS: 30.7% (P = 0.03)
Sihoe et al[35]	nVATS: 68 cVATS: 61	45 ± 19 min	3 ± 25 mL	2.4 ± 0.8 d	3.8 ± 2.2 d nVATS < cVATS (P = 0.07)	10-point VAS mean score: nVATS < cVATS (trend)	Up to 60 mo	nVATS: 2.9% cVATS: 8.2% (P = 0.31)	-	10-point VAS mean score: nVATS < cVATS (P = 0.04)

cVATS: Conventional VATS; nVATS: Needlescopic VATS; uVATS: Uniportal VATS; VAS: Visual analog scale; VATS: Video assisted thoracic surgery.