M. U. Mallicote1, P. Delaplain1, C. Gayer1 1Children’s Hospital Los Angeles,Pediatric Surgery,Los Angeles, CA, USA
Introduction: Lack of consensus exists regarding the management of primary spontaneous pneumothorax (PSP), especially if and when to consider operative management. We hypothesized that patients presenting with a PSP greater than 2 cm on X-ray would more likely to fail non-operative management.
Methods: A single-center, retrospective review was performed over a 10-year period for patients presenting with PSP. Demographics and possible clinical predictors were collected. Initial chest x-rays were evaluated for presence of pneumothorax and categorized as trace, < 2 cm, and > 2 cm measured from chest wall to lung parenchyma from either the apex or lateral chest wall, whichever was greatest. Patients that were managed operatively vs. non-operatively were compared. Chi-square and Student’s t-tests were used as appropriate.
Results: 67 patients were identified as having PSP. Most patients were male between the ages of 14 and 18. Approximately one-third of patients were initially managed non-operatively (oxygen therapy only) with only one treatment failure requiring chest tube. The operative group (unilateral VATS, blebectomy, talc pleurodesis) were more likely to have PSP > 2 cm on x-ray when compared to the non-operative group (70.4% vs. 42.5%, p=0.030). Those with CT scans were also more likely to have a persistent pneumothorax (77.8% vs. 10.0%, p < 0.0001) and multiple bilateral blebs (38.9% vs. 5.0%, p=0.025). LOS was greater at 8.4 days (SD 4.3) compared to the nonoperative group of 3.8 days (SD 5.2).
Conclusion: Determining the need for and timing of operative management in PSP is challenging. Our findings suggest that patients who initially present with a PSP of > 2 cm or have a persistent pneumothorax on chest CT despite chest tube management are unlikely to be treated by chest tube alone and may benefit from earlier operative intervention.