Recurrence Rates After Video-Assisted Thoracoscopic Surgery for Spontaneous Pneumothorax

Abstract

Background:

Video-assisted thoracoscopic surgery (VATS) with pulmonary apical wedge resection is the mainstay procedure performed for spontaneous pneumothorax (sPTX). However, there is variability in adjunctive techniques, including pleurectomy or mechanical pleurodesis, used to prevent recurrences. The objectives of this study were to determine sPTX recurrence rates after initial VATS and to compare the efficacy of adjunct pleurectomy versus mechanical pleurodesis.

Methods:

Patients 11–21 years old who experienced sPTX and underwent initial VATS from December 2011 to December 2020 were identified at a single institution. Descriptive analyses and statistical tests were performed to identify factors associated with ipsilateral sPTX recurrence after surgery.

Results:

Fifty-six patients (48 males) underwent 58 VATS. The majority of patients were white (82.1%), male (85.7%), and nonsmokers (78.6%). Pleurectomy was performed in 27 (46.5%) cases, mechanical pleurodesis in 25 (43.1%), and pleurectomy with mechanical pleurodesis in 6 (10.3%). Overall, 15 patients (25.9%) experienced a postoperative recurrence, of which 8 (13.8%) required intervention. Recurrences occurred between 7 and 800 days after the index procedure. There was no significant difference in rates of overall recurrence between pleurectomy, mechanical pleurodesis, and pleurectomy with mechanical pleurodesis [7/27 (25.9%); 7/25 (28.0%); 1/6 (16.7%): P = .99] or recurrences requiring intervention between the three adjunctive techniques (5/27; 3/25; 0/6: P = .66).

Conclusion:

Over 25% of patients experience recurrence of sPTX after VATS. Recurrence rates were similar whether pleurectomy, mechanical pleurodesis, or pleurectomy with pleurodesis was performed. Further multi-institutional and prospective studies are needed to establish the optimal strategy to limit recurrence rates for pediatric patients with sPTX.

Introduction

Primary spontaneous pneumothorax (sPTX) most commonly occurs in young, tall, thin males and affects patients without known underlying intrinsic lung disease.^1,2 It remains a common indication for thoracic surgical intervention in adolescents with an age-adjusted annual incidence of 7.4–18 per 100,000 in males and 1.2–6 per 100,000 in females in the United States. Initial sPTX are frequently treated with simple aspiration or thoracostomy tube insertion, but the risk for recurrence approaches 50%.^1,3–6

While surgical intervention beyond simple aspiration or tube thoracostomy is often reserved for instances of recurrent sPTX, persistent air leaks, or patients at higher risk for recurrence, a body of literature supports the application of thoracoscopic intervention at the time initial presentation.^3,5,7 Video-assisted thoracoscopic surgery (VATS) with pulmonary apical wedge resection has become the mainstay for surgical treatment at most centers. However, the risk for sPTX recurrence persists.^1,3,4,8–10 Adjunctive techniques, including pleurectomy and mechanical or chemical pleurodesis, have been utilized to try to further decrease recurrence rates. In adult literature, some studies have shown similar recurrence rates between mechanical pleurodesis and wedge resection alone.^4,11 Other studies have reported that mechanical pleurodesis has lower risks of complications and is as effective in preventing recurrence when compared to pleurectomy.^1,12

The available evidence on the use of adjunctive techniques in thoracoscopic surgery for sPTX is limited to small retrospective adult studies, which demonstrate variable outcomes.^4,5,7,8,13 The optimal surgical technique to prevent sPTX in children remains unknown. The objectives of this study were to determine pneumothorax recurrence rates after initial VATS in pediatric patients and to compare the longitudinal efficacy of adjunct pleurectomy versus pleurodesis.

Materials and Methods

Study cohort

This study (STUDY00000156) was approved by the Institutional Review Board of Nationwide Children's Hospital (Columbus, OH), with appropriate waiver of consent obtained. Patients aged 11–21 years of age who experienced sPTX and underwent their initial VATS from December 2011 to December 2020 were retrospectively identified at a single institution. A subsequent chart review using the electronic medical record (EMR) was performed to collect data.

Data collection

Within the EMR, operative notes, history and physical examinations, discharge summaries, clinic notes, and imaging (chest X-rays, computed tomography [CT] scans) were utilized to record the age, gender, race, ethnicity, number of prior sPTX, initial interventions (observation, pigtail insertion, thoracostomy tube placement, or VATS), operative approach, apical wedge resection, staple load used, and adjunctive techniques (pleurectomy, mechanical pleurodesis, chemical pleurodesis, and pleurectomy with mechanical/chemical pleurodesis). Postoperative length of stay (LOS) was defined by procedure date through discharge date. Thirty-day hospital return, 30-day hospital readmission, and 30-day readmission to the operating room (OR) were also recorded to determine complication rates.

Patients undergoing bilateral initial VATS were counted once for patient-level data analysis, but were each considered to contribute two separate procedures (right VATS and left VATS) for VATS-level data analysis (n = 58). Each respective VATS was coded corresponding to the adjunctive technique performed on that side. Procedures were performed by a pediatric general surgeon or pediatric cardiothoracic surgeon. Based on surgeon preference, pleurectomy, mechanical pleurodesis, or pleurectomy with mechanical pleurodesis was performed. Pleurectomy was performed by creating a window into the subpleural space with blunt and/or sharp dissection and removing the parietal pleura from the chest wall with blunt dissection or hydrodissection with irrigation. Mechanical pleurodesis was performed with an electrocautery cleaning pad at the apex of the parietal pleura and circumferentially along the surrounding pleura.

Statistical analysis

Descriptive analyses were performed to describe demographic, clinical, operative characteristics as well as outcomes of sPTX patients undergoing VATS with pleurectomy, mechanical pleurodesis, or combination of pleurectomy with mechanical pleurodesis. Chi-square or Fisher's exact test was used to compare frequencies of categorical variables across the three adjunctive techniques. One-way analysis of variance or Kruskal-Wallis tests were used to compare continuous variables based on their distributions. Statistical significance of α < 0.05 was used, and all analyses were performed with SAS enterprise guide 8.1 (SAS Institute, Inc., Cary, NC).

Results

Cohort description

Fifty-six patients (48 males) underwent 58 initial VATS for sPTX. Two patients underwent bilateral initial VATS—1 with bilateral pleurectomy and 1 with bilateral pleurectomy with mechanical pleurodesis. Of the 58 VATS performed, 27 (46.5%) used adjunctive pleurectomy, 25 (43.1%) used mechanical pleurodesis, and 6 (10.3%) used pleurectomy with mechanical pleurodesis. Chemical pleurodesis was not performed as an adjunct to initial VATS in this cohort. The mean age of the cohort was 16.6 years (standard deviation: 1.8), and a majority of patients were male (85.7%) and nonsmokers (78.6%). Race among the cohort was 82.1% white, 8.9% Asian, 7.1% black, and 1.8% multiracial/other. There were no significant differences in age, gender, race, or smoking status across adjunctive therapies (pleurectomy, mechanical pleurodesis, and pleurectomy with mechanical pleurodesis) (Table 1).

Table 1.

Demographic and Clinical Characteristics of the Patients Undergoing Video-Assisted Thoracoscopic Surgery for Spontaneous Pneumothorax

	Mean/total n (%) (n = 56)	Patients undergoing pleurectomy (n = 26)	Patients undergoing mechanical pleurodesis (n = 25)	Patients undergoing pleurectomy and mechanical pleurodesis (n = 5)	P
Age (mean ± SD)	16.6 ± 1.8	16.6 ± 2.0	16.4 ± 1.7	17.7 ± 0.9	.23^a
Race
White	46 (82.1)	21 (80.8)	21 (84.0)	4 (80.0)	.74^b
Black	4 (7.1)	2 (7.7)	2 (8.0)	0
Asian	5 (8.9)	3 (11.5)	1 (4.0)	1 (20.0)
Multi/other	1 (1.8)	0	1 (4.0)	0
Gender
Male	48 (85.7)	21 (80.8)	22 (88.0)	5 (100)	.63^b
Female	8 (14.3)	5 (19.2)	3 (12.0)	0
Smoking status
No	44 (78.6)	21 (80.8)	18 (72.0)	5 (100)	.68^b
Yes	7 (12.5)	2 (7.7)	5 (20.0)	0
Passive smoke exposure	5 (8.9)	3 (11.5)	2 (8.0)	0
First sPTX	20 (35.7)	9 (34.6)	10 (40.0)	1 (20.0)	.77^b
Number of previous sPTX (median, IQR)	1 (0–1)	1 (0–1)	1 (0–1)	1 (1–2)	.25^c
Symptomatic on presentation	52 (92.9)	22 (84.6)	25 (100)	5 (100)	.18^b
Initial intervention
Observation	6 (10.7)	3 (11.5)	2 (8.0)	1 (20.0)	.54^b
Pigtail insertion	25 (44.6)	9 (34.6)	13 (52.0)	3 (60.0)
Thoracostomy tube	11 (19.6)	7 (26.9)	3 (12.0)	1 (20.0)
VATS	14 (25.0)	7 (26.9)	7 (28.0)	0
Laterality
Right	18 (32.1)	6 (23.1)	11 (44.0)	1 (20.0)	.13^b
Left	36 (64.3)	19 (73.1)	14 (56.0)	3 (60.0)
Bilateral	2 (3.6)	1 (3.8)	0	1 (20.0)

One-way ANOVA test.

Fisher exact test.

Kruskal-Wallis test.

ANOVA, analysis of variance; IQR, interquartile range; SD, standard deviation; sPTX, spontaneous pneumothorax; VATS, video-assisted thoracoscopic surgery.

Twenty patients (35.7%) underwent initial VATS for their first sPTX, and there was no difference in the distribution of these patients across pleurectomy, mechanical pleurodesis, and pleurectomy with mechanical pleurodesis [9/26 (34.6%); 10/25 (40.0%); 1/5 (20.0%): P = .77] (Table 1). In the 36 patients who underwent VATS for their second or greater sPTX, the median number of previous sPTX experienced patients overall was 1 (interquartile range [IQR]: 0–1), and the median number of previous sPTX did not differ across adjunctive techniques (P = .25). A majority of patients presented with left-sided sPTX (36/56, 64.3%) and 2 (3.6%) presented with bilateral sPTX. Most patients were symptomatic, consisting of pain and/or shortness of breath, on presentation (52/56, 92.9%). The initial intervention performed for most patients at their VATS admission was tube drainage (36/56, 64%) with either pigtail insertion (25/56, 44.6%) or thoracostomy tube placement (11/56, 19.6%), followed by VATS (14/56, 25%), and observation (6/56, 10.7%) (Table 1). Wedge resection was performed in 56/58 VATS (96.6%) (Table 3).

Table 3.

Recurrent Spontaneous Pneumothorax Rates, Clinical Findings, and Operative Characteristics of Video-Assisted Thoracoscopic Surgery Performed

	Total/Median n (%) (n = 58)	VATS with pleurectomy (n = 27)	VATS with mechanical pleurodesis (n = 25)	VATS with pleurectomy and mechanical pleurodesis (n = 6)	P
First recurrence	15 (25.9)	7 (25.9)	7 (28.0)	1 (16.7)	.99
Requiring intervention (pigtail insertion, thoracostomy tube, VATS)	8 (13.8)	5 (18.5)	3 (12.0)	0	.66
Requiring VATS	5 (8.6)	2 (7.4)	3 (12.0)	0
Second recurrence	4 (26.7)	3 (42.9)	1 (14.3)	0	.75^a
Duration before first recurrence of sPTX (Median days, IQR)	97 (26–209)	97 (17–143)	145 (26–425)	42	.5^a
CT scan performed	36 (62.1)	17 (62.9)	15 (60.0)	4 (66.7)	.96^b
CT scan findings	n = 36	n = 17	n = 15	n = 4	.98
Ipsilateral blebs	16 (44.4)	7 (41.2)	7 (46.7)	2 (50.0)
Contralateral blebs	3 (8.4)	1 (5.9)	2 (13.3)	0
Bilateral blebs	16 (44.4)	8 (47.1)	6 (40.0)	2 (50.0)
No blebs	1 (2.8)	1 (5.9)	0	0
Blebs observed in OR	53 (91.4)	24 (88.9)	23 (92.0)	6 (100)	1.0
Apical wedge resection performed	56 (96.6)	26 (96.3)	24 (96.0)	6 (100)	.99
Stapler load used for wedge resection^a
Purple	20 (34.5)	13 (48.1)	7 (28.0)	0	.16
White	13 (22.4)	6 (22.2)	5 (20.0)	2 (33.3)
Blue	7 (12.1)	1 (3.7)	4 (16.0)	2 (33.3)
Gold	1 (1.7)	1 (3.7)	0	0
Multiple	3 (5.2)	0	2 (8.0)	1 (16.7)
Other	11 (18.9)	5 (18.5)	5 (20.0)	1 (16.7)

Kruskal-Wallis test.

Fisher's exact test.

CT, computed tomography; IQR, interquartile range; OR, operating room; sPTX, spontaneous pneumothorax; VATS, video-assisted thoracoscopic surgery.

Recurrence rates overall

Overall, there were 15/58 (25.9%) sPTX recurrences following initial VATS. In patients with a recurrence, 8/58 (13.8%) required intervention (defined as pigtail insertion, thoracostomy tube placement, or VATS). Five patients required a second VATS (5/58, 8.6%). Recurrences occurred in a range from 7 to 800 days after index procedure. Table 2 compares ipsilateral sPTX recurrence after VATS to no recurrence. Age and gender did not differ between those who experienced sPTX recurrence and those who did not (16.8 ± 1.6; 16.5 ± 1.9; P = .56; male versus female, P = .66). Number of previous sPTX (P = .13), postoperative air leaks (P = .99), and adjunctive technique used during VATS (P = .99) were similar between those with and without recurrence. There was also no difference in recurrence whether patients were experiencing their first sPTX or their second or greater sPTX (P = .22) (Table 2).

Table 2.

No Recurrence Versus Recurrence After Primary Video-Assisted Thoracoscopic Surgery for Spontaneous Pneumothorax

	All (58)	Recurrence (15)	No recurrence (43)	P
Age (mean ± SD)	16.8 ± 1.8	16.8 ± 1.6	16.5 ± 1.9	.56
Gender
Male	50 (86.2)	14 (93.3)	36 (83.7)	.66^a
Female	8 (13.8)	1 (6.7)	7 (16.3)
Pleurectomy	27 (46.6)	7 (46.7)	20 (46.5)	.99^a
Mechanical pleurodesis	26 (43.1)	7 (46.7)	19 (41.8)
Pleurectomy and mechanical pleurodesis	6 (10.3)	1 (6.7)	5 (11.6)
Number of previous sPTX (median, IQR)	1 (1–0)	1 (1–1)	1 (0–1)	.13^a
First episode of sPTX	20 (34.5)	3 (20.0)	17 (39.5)	.22^a
Second or greater episode of sPTX	38 (65.5)	12 (80.0)	26 (60.5)
Postoperative air leak	44 (75.9)	12 (80.0)	32 (74.4)	.99

Fisher's exact test.

IQR, interquartile range; SD, standard deviation; sPTX, spontaneous pneumothorax.

Recurrence rates by adjunct procedure performed

Incidence of recurrence following VATS with pleurectomy was 25.9%, 28% following VATS with mechanical pleurodesis, and 16.7% following VATS with pleurectomy and mechanical pleurodesis. There was no significant difference in recurrence between pleurectomy, mechanical pleurodesis, and pleurectomy with mechanical pleurodesis (7/27; 7/25; 1/6: P = .99) or in recurrences requiring intervention between the three adjunctive techniques (5/27 versus 3/25 versus 0/6, P = .66) (Table 3). The overall median duration from primary VATS to sPTX recurrence was 97 days (IQR: 26–209). Patients who underwent pleurectomy had a median interval to recurrence of 97 days (IQR: 17–143), while patients who underwent mechanical pleurodesis had a median interval to recurrence of 145 days (IQR: 26–425), and 1 pleurectomy with pleurodesis patient had recurrence (42 days). No statistical difference was seen in median time to occurrence across adjunctive techniques (P = .5) (Table 3).

Recurrence rates by presence of blebs

Of patients who underwent VATS, 36/56 (62.1%) had a CT scan performed before surgery. CT findings in these patients demonstrated that 44% (16/36) had ipsilateral blebs, 8.4% (3/36) had contralateral blebs only, 44.4% (16/36) had bilateral blebs, and 2.8% (1/36) had no blebs. There were no differences in CT findings seen across adjunctive techniques (P = .98) (Table 3). When comparing patients who had either ipsilateral or bilateral blebs (32/36) to patients who had either contralateral or no blebs (4/36), there was no difference in recurrence rate (25%, 8/32 versus 25%, 1/4; P = 1.0) (Table 4).

Table 4.

Recurrence Rates Based on Presence of Blebs

	Recurrence
	Recurrence	No recurrence	Total	P
CT scan findings			n = 36
Ipsilateral or bilateral blebs	8 (25.0)	24 (75.0)	32 (88.9)	1.00
Contralateral or no blebs	1 (25.0)	3 (75.0)	4 (11.1)
Blebs observed in OR			n = 58
Yes	12 (22.6)	41 (77.4)	53 (91.4)	.10
No	3 (60.0)	2 (40.0)	5 (8.6)
	Wedge resection
Blebs observed in OR	Yes	No	Total	P
Yes	53 (100)	0	53 (91.4)	<.01
No	3 (60.0)	2 (40.0)	5 (8.6)
	Recurrence
	Recurrence	No recurrence	Total	P
Blebs observed with wedge resection	12 (22.6)	41 (77.4)	53	.55^a
No blebs observed with wedge resection	1 (33.3)	2 (66.7)	3

Fisher's exact test.

CT, computed tomography; OR, operating room.

Blebs were observed in the OR in 53/58 (91.4%) VATS (Table 3). sPTX recurrence occurred in 22.6% (12/53) of patients where blebs were observed and in 60% (3/5) of patient where blebs were not observed (P = .10). All patients where blebs were observed underwent an apical wedge resection (53/53), while 60% (3/5) of patients without blebs underwent an apical wedge resection. There was no significant difference in recurrence rates seen between patients who had blebs observed and underwent apical wedge resection and those without blebs who underwent apical wedge resection (22.6%, 12/53 versus 33.3%, 1/3; P = .55) (Table 4).

Hospital course and outcomes by adjunct procedure performed

Overall, patients underwent a median of 12 (IQR: 9–17) X-rays during their hospital admission for sPTX and initial VATS and 62.5% (35/56) underwent a CT scan. There was no statistical difference in median postoperative LOS across adjunctive pleurectomy, mechanical pleurodesis, and pleurectomy with mechanical pleurodesis (4 days [IQR: 3–6]; 6 days [IQR: 3–9]; 7 days [IQR: 4–8]: P = .06), although clinically pleurectomy patients were discharged 2 days earlier than mechanical pleurodesis patients. Eleven (11/56, 19.6%) patients returned to the hospital within 30 days of VATS. Four pleurectomy patients (4/26, 15.4%) and 2 mechanical pleurodesis patients (2/25, 8.0%) returned with postoperative pain/chest pain. Two pleurectomy patients (2/26, 7.7%), 2 mechanical pleurodesis patients (2/25, 8.0%), and 1 pleurectomy with mechanical pleurodesis patient (1/5, 20.0%) returned with recurrent sPTX. Six patients (6/56, 10.7%) were subsequently admitted to the hospital, and 4 (4/56, 7.1%) returned to the OR. There was no significant difference in 30-day hospital return (P = .88), 30-day hospital readmission (P = .99), or 30-day return to OR (P = .49) across adjunctive techniques (Table 5).

Table 5.

Outcomes Related to Hospital Admission and Surgical Intervention with Video-Assisted Thoracoscopic Surgery with Pleurectomy, Mechanical Pleurodesis, or Pleurectomy with Mechanical Pleurodesis

	Pleurectomy (n = 26)	Mechanical pleurodesis (n = 25)	Pleurectomy and mechanical pleurodesis (n = 5)	P	Median or total n (%) (n = 56)
Postoperative LOS in days (Median, IQR)	4 (3–6)	6 (3–9)	7 (4–8)	.06^a	5 (3–7)
X-rays during admission (Median, IQR)	10 (8–16)	14 (10–20)	15 (13–19)	.13^a	12 (9–17)
Number returned to hospital within 30 days, N %	6 (23.1)	4 (16.0)	1 (20.0)	.88	11 (19.6)
Reason for hospital return
Postoperative pain/chest pain	4 (66.7)	2 (50.0)	0		6 (54.6)
Recurrent sPTX	2 (33.3)	2 (50.0)	1 (100.0)		5 (45.4)
Number readmitted to hospital within 30 days, N (%)	3 (11.5)	2 (8.0)	1 (20.0)	.99	6 (10.7)
Number returned to OR within 30 days, N (%)	2 (7.7)	1 (4.0)	1 (20.0)	.49	4 (7.1)

Kruskal-Wallis test.

CT, computed tomography; IQR, interquartile range; LOS, length of stay; OR, operating room; sPTX, spontaneous pneumothorax.

Discussion

In this cohort of 56 patients undergoing 58 initial VATS, greater than 25% experienced sPTX recurrence, and over half of those with recurrences required an intervention. There were no significant differences in recurrence rates or recurrences requiring intervention across adjunctive techniques.

Previous adult studies have demonstrated varying results of pleurectomy and mechanical pleurodesis. Several have found pleurectomy to reduce recurrence rates compared to mechanical pleurodesis.^14,15 Others demonstrate no difference between pleurectomy and mechanical pleurodesis.^4,12 One study with a mean patient age of 25 years demonstrated that 4.6% of pleurectomy patients had a sPTX recurrence compared to 6.2% of mechanical pleurodesis patients (P = .82). The recurrence rates in adult studies are notably lower than in our cohort. Pediatric sPTX recurrence data after VATS are limited. A recent single-institution pediatric study analyzed 59 children (mean age 15.7 years) who underwent 64 operations (open thoracotomy or VATS with apical wedge resection) for sPTX. They demonstrated a similar overall sPTX recurrence of 23.4% (15/64) compared to our cohort. However, they reported a significantly higher recurrence rate in mechanical pleurodesis patients (40.0%) compared to patients who underwent pleurectomy (8.8%, P = .004).³

The time interval at which patients in our study experienced a sPTX recurrence after VATS was not significantly different among patients undergoing pleurectomy, mechanical pleurodesis, and pleurectomy with mechanical pleurodesis. However, the median time to recurrence was clinically 97, 145, and 42 days, respectively. In the study by Joharifard et al., patients had an average time to sPTX recurrence after index operation of 357 days in patients undergoing pleurectomy and 568.5 days in patients undergoing mechanical pleurodesis (P = .41).³ From a statistical standpoint, our study was similar in that we did not see differences in time to recurrence across adjunctive techniques. Clinically, our patients had a shorter time to sPTX recurrence after pleurectomy and mechanical pleurodesis in comparison. The reason for this finding is unclear, but varying rates for time to recurrent sPTX in pleurectomy and mechanical pleurodesis patients have been published in adult literature.^16–18 Imperatori et al. studied adults (mean age 25 years) undergoing VATS and pleurectomy and reported a median time to recurrence of 43 months (∼1300 days).¹⁷ Gossot et al. demonstrated that out of 111 adults who underwent VATS with mechanical pleurodesis, only 4 patients had recurrences at 2, 42, 49, and 82 months, although the average age of their cohort was 31.6 years.¹⁶ Contradictory to these results, in a randomized controlled trial published by Min et al., half of the patients (mean age 22 years) undergoing VATS and mechanical pleurodesis recurred within 3 weeks.¹¹

In addition to recurrence rates and time to recurrence, varying outcomes have been reported on the complications resulting from adjunctive therapies.^1,3,4,11,12 Our study showed similar proportions of 30-day hospital presentation, 30-day hospital readmission, and 30-day return to OR among pleurectomy, mechanical pleurodesis, and pleurectomy with mechanical pleurodesis patients. Of patients presenting to the hospital within 30 days, residual postoperative chest pain/discomfort and recurrent sPTX were the reasons for return. Although not specifically defined, Joharifard et al. also reported a similar incidence of short-term postoperative complications among patients undergoing pleurectomy and mechanical pleurodesis.³ Some adult studies have reported pleurectomy patients to more frequently experience a hemothorax postoperatively and have greater residual chest pain compared to mechanical pleurodesis patients.^4,12 Rena et al. reported that apical pleurectomy patients experienced significantly more residual chest pain/discomfort than mechanical pleurodesis patients.^4,12 Chen et al. reported an incidence of hemothorax in 3.8% of patients (mean age 26.3 years) who underwent pleurectomy and more bleeding during surgery compared to chemical pleurodesis (29.4 mL versus 13.2 mL, P = .025), but long-term residual chest pain and pulmonary function were similar among patients.^1,4

Limitations

Our study had several limitations. First, our study was retrospective in design. Data collection relied on documentation within the EMR, which could potentially introduce information bias. Second, this study focused on the pediatric population treated at a tertiary children's hospital, so there may be decreased external validity when trying to apply these results to the general population. Third, we did not use chemical pleurodesis, staple line coverage techniques, or lung fixation techniques as comparison groups, as these are not commonly used at our institution. Further studies would be necessary to make comparisons among these techniques. Finally, our sample size was relatively small, which decreased the power of the study to detect differences between groups.

Conclusion

Recurrence rates after VATS for sPTX in children are high. Adjunctive pleurectomy, mechanical pleurodesis, and pleurectomy with mechanical pleurodesis were found to have a similar incidence of recurrence and time to sPTX recurrence. The available evidence is limited and reports have varying results. Larger multi-institutional and prospective studies are warranted to identify the best treatment for pediatric sPTX.

Footnotes

Authors' Contributions

Each author has participated sufficiently in the work to take public responsibility for appropriate portions of the article contents. Study conception and design: K.N.P., A.E.L., T.J.B., J.H.A., M.M., and P.C.M. Data acquisition: K.N.P., A.E.L., T.J.B., J.H.A., M.M., and P.C.M. Analysis and data interpretation: K.N.P., T.J.B., J.H.A., M.M., and P.C.M. Drafting of the article: K.N.P., T.J.B., J.H.A., M.M., and P.C.M. Critical revision: K.N.P., A.E.L., T.J.B., J.H.A., M.M., and P.C.M.

Disclosure Statement

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article.

Funding Information

No funding was received for this article.

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