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ORIGINAL ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 11  |  Page : 1669-1673

Analysis of patients undergoing surgical treatment for primary spontaneous pneumothorax


1 Department of Thoracic Surgery, Fırat University Faculty of Medicine, Elazig, Turkey
2 Department of Thoracic Surgery, Health Sciences University Gazi Yasargil Education and Research Hospital, Diyarbakir, Turkey

Date of Submission18-Jun-2020
Date of Acceptance16-Apr-2021
Date of Web Publication15-Nov-2021

Correspondence Address:
Dr. M Cakmak
Department of Thoracic Surgery, Fırat University Faculty of Medicine, Elazig
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_361_20

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   Abstract 


Background: Primary spontaneous pneumothorax (psp) results from spontaneous rupture of bleb or bulla. Aims: We planned to discuss the etiologic factors, clinical and radiological findings, and treatment results of psp cases. Materials and Methods: 402 patients were evaluated. Patients were divided into two groups as patients receiving positive results with thoracostomy and patients who received positive results thoracotomy/video-assisted thoracoscopic surgery (vats). Groups were compared. Results were evaluated using Chi-square or Fishers' exact test. P < 0.05 was considered as significant. Results: Gender difference (P: 1.00) and localization of disease (P: 0.45) were not significant for psp. Smoking and being subtotal or total compared to partial had a substantial effect on the implementation of thoracotomy/vats (P < 0.05). Furthermore, psp was most frequently seen in August and September. Discussion: Risk factors of psp are described as genetic predisposition, being tall, smoking, and autosomal dominant heredity. The main determinant factor in the treatment of psp is the degree of pneumothorax. Conclusion: Psp was frequently observed in smokers. The preferred method for overall psp is tube thoracostomy. Thoracotomy/vats is more commonly performed for subtotal or total psp compared to partial psp.

Keywords: Pneumothorax, spontaneous, thoracostomy, thoracotomy


How to cite this article:
Cakmak M, Durkan A. Analysis of patients undergoing surgical treatment for primary spontaneous pneumothorax. Niger J Clin Pract 2021;24:1669-73

How to cite this URL:
Cakmak M, Durkan A. Analysis of patients undergoing surgical treatment for primary spontaneous pneumothorax. Niger J Clin Pract [serial online] 2021 [cited 2021 Nov 26];24:1669-73. Available from: https://www.njcponline.com/text.asp?2021/24/11/1669/330460




   Introduction Top


Pneumothorax, occurring spontaneously or after trauma to lung or chest wall, is defined as air or gas accumulation in the pleural cavity. Spontaneous Pneumothorax (sp) can be classified as primary (psp) or secondary (ssp). While psp that results from spontaneous rupture of a subpleural bleb or bulla occurs predominantly in young and thin males without underlying lung diseases, ssp is seen older people with underlying pulmonary diseases such as emphysema, asthma, infections, catamenial pneumothorax, and lymphangioleiomyomatosis.[1],[2] Psp may be associated with congenital diseases as Marfan's syndrome or environmental factors as smoking. Therefore, there are some precipitating factors, such as change in atmospheric pressure and emotional change.[3],[4] Incidence of psp is %7.4-18 for males whereas it is %1.2-6 for females.[1] There is a positive family history in %10 of the patients with psp and gene mutations have been reported in some patients.[5],[6]

The most clinical finding is local pleuritic chest pain accompanied by shortness of breath. The complaints may be acute onset and resolved within 24 hour even though pneumothorax still exists. Tension pneumothorax is a serious complication. In patients with tension pneumothorax, severe shortness of breath and signs of shock are observed, which requires immediate intervention.[1],[7]

Diagnosis is usually made by chest x-ray and clinical findings. Computed tomography can be used for detecting patients with small pneumothorax and the number, size, and location of bullae or blebs. Therefore, pleural adhesion, pleural fluid, and underlying pulmonary diseases are detected with computed tomography.[7] The patients with psp are treated with surgical or non-surgical procedures. While surgical procedures are tube thoracostomy and thoracotomy/video-assisted thoracoscopic surgery (vats), non-surgical procedures are oxygen supplementation and observation.[8],[9],[10]

In our study, we aimed to share etiologic factors, clinical and radiological findings, and treatment results of psp cases that were surgically treated and followed by our clinic.


   Materials and Methods Top


Patients

We retrospectively evaluated 402 patients with psp, who were treated with surgical procedures and admitted to our clinic in the past ten years.

Study design

Patients were divided into two groups as patients who received positive results with tube thoracostomy and patients who received positive results thoracotomy/vats. The age of the patients, gender, symptoms, vital signs, habits, diagnostic methods, the localization of the disease, pneumothorax types-rates, applied treatments, complications, and length of stay in hospital were identified. Pneumothorax rate was determined by chest x-ray and Rhea method. Patients were divided into 4 groups as minimal (<%20), partial (%20-39), subtotal (%40-59) and total pneumothorax (>%60). The project titled ''Analysis of patients undergoing surgical treatment for primary spontaneous pneumothorax'' has been approved by Ethics Committee of Dicle University Faculty of Medicine. Confirm date; 27.02.2015-Number; 118.

Inclusion and exclusion criteria

Patients who were observed to have positive results and were not treated surgically were excluded from the study.

Statistical analysis

Continuous variables of statistical analysis were described as mean ± standard deviation, while categorical variables were expressed as number and percentage. Results were assessed using Chi-square test or Fishers' exact test. P < 0.05 was considered significant.

Ethics

Our retrospective study has been approved by Ethics Committee of Dicle University, Faculty of Medicine.


   Results Top


The mean age of patients was 28.4 ± 6.6. Psp was most frequently seen between 23-30 years of age. 372 (%93) of the patients were male, whereas 30 (%7) were female. Gender difference was not significant for patients with psp (P: 1.00). There was a positive family history in nine patients with psp.

Disease was localized in the right lung in 239 (%59) patients, while it was on the left in 163 (%41). Localization of disease was not significant in terms of psp (P: 0.45). The number of patients with psp who smoke was 313 (%78) [Graph 1]. Smoking rate in patients with psp was 3.51. Smoking habit was found to have a substantial effect in terms of implementation of thoracotomy/vats for patients with psp (P: 0.02) [Table 1].

Table 1: Analysis of patients undergoing surgery

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While psp was seen most frequently in August (n = 43, (%11)) and September (n = 42, (%10)), it was least frequently observed in November (n = 22, (%5)) and October (n = 24, (%6)), [Graph 2]. 164 (%41) of patients with psp were partial [Figure 1], 81 (%20) were subtotal [Figure 2], and 157 (%39) were total [Figure 3] and [Graph 3]. 144 (%88) of the patients with partial pneumothorax were performed tube thoracostomy, while 20 (%12) had thoracotomy/vats. 63 (%78) of the subtotal pneumothorax patients were treated with tube thoracostomy, whereas 18 (%22) underwent thoracotomy/vats. 111 (%71) of total pneumothorax patients got tube thoracostomy, while 46 (%29) were performed thoracotomy/vats. It was seen that being subtotal (P: 0.05) or total (P: 0.0002) compared to partial had a substantial effect in terms of the implementation of thoracotomy/vats. Thoracotomy/vats indications for patients with psp were identified as prolonged air leak and expansion defect in 30 (%36) patients, the second attack in 49 (%58), and the third attack in 5 (%6) of the patients [Table 2].

Figure 1: Image of partial primary spontaneous pneumothorax

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Figure 2: Image of subtotal primary spontaneous pneumothorax

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Figure 3: Image of total primary spontaneous pneumothorax

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Table 2: Conditions requiring surgical treatment in our primary spontaneous pneumothorax patients

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The most common complications encountered were empyema and atelectasis. No mortality was seen. And the mean length of stay was 6.8 ± 3.4 days.


   Discussion Top


For some of the patients with primary spontaneous pneumothorax, autosomal dominant heredity plays a role and is reported to be higher in men.[11] In patients with spontaneous pneumothorax, the most frequent symptom is chest pain and dyspnea.[11],[12] Chiu et al.[13] reported that there is a relationship between spontaneous pneumothorax and HLA2B40 and M1M2 phenotypes of alpha-1 antitrypsin. Many studies reported that smoking is a risk factor.[10],[13],[14] In our study, there was a positive family history in nine patients with psp. Smoking rate in patients with psp was 3.51 (use/not use: 313/89).

In a study conducted on 197 patients with spontaneous pneumothorax, the mean age for psp was found to be 26.8.[11] Psp is common between the ages of 25-34.[10] Gutpaa et al.[15] reported that the incidence of psp was 16.7 for men and 5.8 for women. In our study, psp was most commonly seen between 21-30 years of age.

Primary spontaneous pneumothorax is more commonly observed in the right hemithorax for unknown reasons.[16] Similarly, it was seen more often in the right hemithorax in our study. Turker et al.[16] found that spontaneous pneumothorax is more frequent in the fall, whereas Gurbuz et al.[17] stated that it is more common in the spring. In our study, PSP was frequently seen in August and September.

The diagnosis of pneumothorax can approximately be provided by means of history, physical examination, and chest x-ray. However, in cases where discrimination of pneumothorax and bullae remains unclear, correct diagnosis can be established by using computed thorax tomography.[18] In our study, the diagnosis was usually performed by chest radiograph. In some cases, computed tomography was the other method used to distinguish between blisters and pneumothorax.

Minimal pneumothorax cases are below %20. The level between %20-39 is considered as partial pneumothorax, %40-59 is accepted as subtotal pneumothorax, and %60 and above is total pneumothorax. The main determinant factor in the treatment of psp is the degree of pneumothorax. In minimal pneumothorax, observation and oxygen therapy are sufficient.[19] The preferred method for overall spontaneous pneumothorax is tube thoracostomy. Additionally, tube thoracostomy is usually applied from fifth and sixth intercostal space in the mid-axillary line. In the case of not developing expansion for 7-10 days after tube thoracostomy, surgical procedure is carried out. Some other publications recommending surgery in the case of not being expanded following 3-4 days after tube thoracostomy are also available.[20] Other surgical indications are prolonged air leakage, non-expanded lung, bilateral pneumothorax, hemothorax development, and tension and total pneumothorax.[21]

In the surgical approach, bullae resection, standard thoracotomy, axillary thoracotomy, and vats can be applied. Today, mostly stapler, blebectomy, and pleural abrasion are preferred because of the low complication risk.[20] The main surgical procedures usually performed on patients with spontaneous pneumothorax are bullae excision and pleurectomy. However, the pleural abrasion and pleurodesis are the other treatment methods to be applied even if they are performed in relatively small numbers.

In our study, psp rates were partial for 164 patients (%41), subtotal in 81 patients (%20), and total in 157 patients (%39). 144 (%88) of the patients with partial psp were applied tube thoracostomy, while 20 (%12) were treated via thoracotomy/vats. 63 of (%78) the patients with the subtotal psp were performed tube thoracostomy, whereas 18 of (%22) were applied thoracotomy/vats. 111 (%71) of the patients with total psp underwent tube thoracostomy, while 46 (%29) were performed thoracotomy/vats.

Indications of thoracotomy/vats in the patients with psp were prolonged air leak and expansion defect in 30 patients (%36), the second attack for 49 patients (%58) and the third attack in 5 patients (%6). It was seen that gender, localization, and whether being subtotal or total did not affect thoracotomy/vats application. However, smoking, being subtotal compared to partial, and being total compared to partial had substantial effect on thoracotomy/vats implementation.

As a result, pneumothorax is a common chest surgery pathology whose treatment and diagnosis are not difficult. With the help of proper diagnosis methods and treatment techniques, pneumothorax can be controlled. Psp was seen frequently in smokers. The preferred method for overall psp is tube thoracostomy. Thoracotomy/vats is more commonly performed for subtotal or total psp compared to partial psp. However, immediate intervention is required in the case of complications such as tension pneumothorax.

Acknowledgements

We would like to thank all the physicians and service staff who helped in the collection of data. In addition, thanks for the contribution to Ethics Committee of Dicle University of Medicine.

Financial support and sponsorship

There is no conflict of interest including pharmaceutical and industry support in our study.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Turker H, Akkaya E, Koralp F. Evaluation of cases with spontaneous pneumothorax. Respiratory 1993;18:670-6.  Back to cited text no. 16
    
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MacDuff A, Arnold A, Harvey J; BTS Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline. Thorax 2010;65:18-31.  Back to cited text no. 19
    
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Dżeljilji A, Karuś K, Kierach A, Kazanecka B, Rokicki W, Tomkowski W, et al. Efficacy and safety of pleurectomy and wedge resection versus simple pleurectomy in patients with primary spontaneous pneumothorax. J Thorac Dis 2019;11:5502-8.  Back to cited text no. 20
    
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Plojoux J, Froudarakis M, Janssens JP, Soccal PM, Tschopp JM. New insights and improved strategies for the management of primary spontaneous pneumothorax. Clin Respir J 2019;13:195-201.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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