Þórdís Magnadóttir¹

Leon Arnar Heitmann²

Tinna Harper Arnardóttir1

Tómas Þór Kristjánsson¹

Per Martin Silverborn¹

Martin Ingi Sigurðsson^2,3

Tómas Guðbjartsson^1,2

¹Departments of Cardiothoracic Surgery, Landspitali University Hospital, ²Faculty of Medicine, University of Iceland, ³Anesthesia and Intensive Care, Landspitali University Hospital.

Correspondence: Tómas Guðbjartsson, tomasgud@landspitali.is

Key words: primary spontaneous pneumothorax, outcomes, recurrence, smoking.

BACKGROUND: Primary spontaneous pneumothorax (PSP) is a common disease where surgery is indicated for persistant air leak or recurrent pneumothorax. We studied the outcomes of PSP-surgery over a 28 year period in a whole nation.

MATERIALS AND METHODS: A retrospective study on 386 patients (median age 24 years, 78% males) that underwent 430 PSP surgeries at Landspitali University Hospital 1991-2018. Annual incidence of the procedure was calculated and previous medical history, indication and type of surgery, complications and length of hospital stay were registered. Patients in four 7 year periods were compared, recurrent pneumothoraces requiring reoperation (median follow-up 16 years) registered and predictors of reoperation identified with logistic regression.

RESULTS: Annually 14.5 PSP surgeries (median, range 9-27) were performed; the incidence decreasing by 2.9% per year on average. Every other patient smoked and 77% of surgeries were performed with video assisted thoracocopic surgery (VATS). The most common early complications (<30 days from surgery) were persistent airleak (17%), pneumonia (2%) and empyema (0,5%). No patient died within 30 days from surgery. Reoperation for recurrent pneumothorax was performed on 27 patients; 24 following VATS (7%), median time from the primary surgery being 16 months. Logistic regression showed that younger patients were more likely to require reoperation for recurrent pneumothorax.

CONCLUSIONS: Surgical treament for PSP is safe and major early complications rare. The rate of recurrent pneumothorax requiring surgery was 6%, which is similar to other studies. For unknown reasons the incidence of PSP surgery declined, but future research has to answer if it is linked to decreased smoking in the Icelandic population.

*Information regarding weight was missing for 23 patients**Information regarding height of 57 patients was missing

Table II. Indication for surgery
	1991-2018	1991-1997	1998-2004	2005-2011	2012-2018
First pneumothorax	191 (44)	50 (41)	42 (42)	48 (41)	51 (55)
First recurrent pneumothorax	178 (41)	48 (40)	36 (36)	57 (49)	37 (40)
Second or third recurrent pneumothorax	56 (13)	19 (16)	20 (20)	12 (10)	5 (5)
>3 recurrences on ipsilateral lung	5 (1)	4 (3)	1 (1)	0	0
Bilateral pneumothorax	1 (1)	0	1 (1)	0	0

 

 

Table III. Type of surgery, length of surgery og length of hospital stay after surgery

	1991-2018	1991-1997	1998-2004	2005-2011	2012-2018
Wedge resection only	161 (37)	68 (56)	57 (58)	19 (16)	17 (18)
Wedge resection + pleurodesis	216 (50)	52 (43)	41 (41)	58 (50)	65 (70)
Wedge resection + pleurodesis + partial pleurectomy	51 (12)	0 (0,0)	1 (1)	40 (34)	10 (11)
Operative time	52 (40, 68)	60 (40, 75)	45 (35, 65)	50 (42, 65)	52 (37, 67)
Length of hospital stay	3 (2,5)	3 (2, 5)	3 (2, 4)	4 (3, 5)	3 (2, 4)

 

Table IV. Early complications after surgery
Persistent airleak	74 (17)
Bleeding	9 (2)
Pneumonia	7 (2)
Empyema	2 (0,5)
Horners syndrome	1 (0,2)
30 day mortality	0 (0)

 

 

 

Tafla V. Independent predictors for recurrent pneumothorax after surgery for PSP. Odds ratio are shown together with 95% confidence intervals (CI)

 

Figure 1 Incidence during the study period. According to Poisson regression model the incidence decreased significantly, or on average by 2,9% annually.

 

Figure 2 Number and type of operations performed in four 7 year periods. X-axis shows year periods and y-axis shows number of operations.

 

Figure 3. Reversed Kaplan-Meier graph that shows the timing of the recurrent pneumothoraces from the primary surgery.