Approach to pneumothorax surgery: a national survey of current UK practice

Introduction

Pneumothorax is defined as air between the visceral and parietal pleurae. It can be classified as: the presence of chest wound, closed versus open; the presence of tension, simple versus tension; or the presence of trauma, spontaneous versus traumatic. Spontaneous pneumothorax occurs in the absence of trauma and can be further classified into: primary, absence of known pulmonary disease; or secondary, presence of underlying pulmonary disease. The incidence of spontaneous pneumothorax has a bimodal age distribution with a peak in the young (20–30 years) for primary pneumothorax and a peak in the elderly (60–65 years) for secondary pneumothorax. Catamenial pneumothorax occurs in women of childbearing age within 3 days of menstruation. Pneumothorax can be classified as small or large; large being a > 2-cm rim at the hilum or > 3-cm apex-to-cupola distance.^1,2 The 5-year recurrence rate for primary spontaneous pneumothorax is approximately 30%. Surgery to treat and prevent recurrence of pneumothorax involves excision of blebs or bullae and achieving pleural symphysis by mechanical (abrasion, pleurectomy) or chemical (talc, blood, tetracycline) pleurodesis. Minimal access surgery has gained widespread popularity because of the numerous benefits for patients, including but not limited to less pain, quicker recovery, and a shorter hospital stay. ³ Disadvantages of a minimally invasive approach are a conceivably increased recurrence rate.

The British Thoracic Society (BTS) has published guidelines for the management of pneumothorax; the most recent version was published in 2010. ¹ The guidelines offer various evidence-based recommendations for the management of both primary and secondary spontaneous pneumothorax, but exclude traumatic pneumothorax. Despite the existing guidelines, we believe there are variations in practice among surgeons across Great Britain and Ireland. We investigated this scenario by conducting a nationwide survey to evaluate consistency and variability in the surgical management of pneumothorax among surgeons in the United Kingdom.

Methods

An online questionnaire regarding pneumothorax management was generated. The questionnaire was uploaded onto the Survey Monkey website. Consultant members of the Society for Cardiothoracic Surgery (SCTS) in Great Britain and Ireland were identified following a formal request to the society. They were contacted via the society’s email system. A link to the questionnaire was sent to all registered thoracic and cardiothoracic surgery consultants in August 2016. A reminder encouraging participation in the survey was sent via email in October 2016. The survey was concluded in January 2017. The questionnaire (Table 1) asked 10 questions with 5–7 answer options alongside supplementary free-text sections for comments. The results were analyzed and the averages and percentages were calculated.

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Table 1.

The questionnaire regarding pneumothorax management.

Results

There were 80 thoracic and 84 cardiac consultant surgeons registered on the SCTS database in October 2016. Fifty-six consultants from the around the UK responded to the survey, resulting in a response rate of 70%. Interestingly, a total of 123 consultant surgeons were identified as performing lung cancer resections in 2015. ⁴ In terms of surgical approach, 100% of participants preferred video-assisted thoracoscopic surgery (VATS) to a thoracotomy for pneumothorax surgery. Triple-port VATS access was used by the majority (63%), 11 (20%) consultants used a uniportal approach, and the remaining 17% used either approach or even a biportal approach, based on individual cases (Figure 1). The majority of respondents (95%) liked to operate on patients at the first presentation of pneumothorax only in the presence of persistent air leak and/or persistent lung collapse; 41 (73%) would also operate at the first presentation if bilateral, 22 (39%) offer surgical intervention only for recurrent pneumothoraces, and 18 (32%) would also offer surgery at the first presentation of unilateral pneumothorax with evidence of bullae on computed tomography imaging. Interestingly, 9% would propose surgical intervention for patients after the very first episode of simple unilateral spontaneous pneumothorax. Using the free-text boxes, 19 (34%) respondents commented that the above list was not sufficiently inclusive and they would also like to operate at the first presentation with tension, hemopneumothorax, contralateral pneumothorax, and in special circumstances such as a pilot, scuba/deep sea diver, professional driver, elderly with complex bullae, or based on patient choice (Figure 2). For most (46%) respondents, apical bullectomy +parietal pleurectomy was the preferred technique, whereas 13 (23%) consultants preferred a combination of apical bullectomy + apical pleurectomy + pleural abrasion. Only 6 (11%) surgeons would carry out either apical bullectomy + pleural abrasion or combine it with talc pleurodesis, but none did just talc or bullectomy only. Using the free-text box, 18 (32%) respondents provided comments and indicated that parietal pleurectomy may be extended to include the diaphragmatic surface, some would routinely use talc, and some would avoid it, considering it nocuous (Figure 3). The majority (59%) of consultants use a single apical chest drain without or with 24–48 h suction, depending on air leak/lung expansion. A few (8%) surgeons expressed a preference for using both apical and basal drains with > 48 h of suction, and 10 (18%) decided on drainage on a case-by-case basis. Twenty-one (38%) respondents commented that the preference for drains and suction varied depending on lung collapse or complex pleural space, and some mentioned lack of evidence for suction and that a metanalysis has confirmed equipoise. The response to the question on chest radiography was highly variable but the majority (48%) of responses favored immediate postoperative and/or daily chest radiographs (including pre- and post-drain removal). Nine (16%) surgeons chose the option of a day-1 chest radiograph before drain removal if the lung was expanded (not post-drain removal), and 7 (13%) had no fixed requirement for chest radiographs and would rather proceed according to clinical need. Regarding the duration of drainage, the majority (52%) of respondents would drain the pleural space for 48 h, 12 (21%) until the drain stops swinging/no air leak, 6 (11%) routinely for 72 h, and 3 (5%) for 24 h only. Fourteen (25%) respondents commented that drain swing has no relevance in this context, but air leak has a particular influence on the decision (<20 mL for 2–6 h; Figure 4). Currently, most (59%) consultant thoracic surgeons in the United Kingdom use a digital drainage system, but 22 (39%) still rely on a traditional underwater seal drain. A few surgeons remarked that digital drains were a waste of money in this group, and found early mobilization was the only useful aspect. With regard to perceived chronic pain, the answers reflected a short range of variability: 12 (21%) reported 5% chronic pain, 11 (20%) reported 1%, 10 (18%) reported 2%, 6 (11%) reported 3%, and another 6 (11%) selected the option of no chronic pain. Using the free-text box, 16 (29%) respondents commented that it was difficult to answer with certainty due to the lack of long-term follow-up, and this is worth a separate study/survey. Finally, the response to the observed recurrence rate was variable: most (29%) chose the option of 1% recurrence, 14 (25%) chose 2%, 10 (18%) went for 3%, and 6 (11%) reported 5%, while another 6 (11%) experienced consultants observed no recurrence in their long-term practice. Eighteen (32%) commented that it was a guess, although some had observed recurrences in patients who were on nonsteroidal antiinflammatory drugs (Figure 5).

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Figure 1.

Participants and their preferred surgical approach.

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Figure 2.

When would you operate for spontaneous pneumothorax?

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Figure 3.

What is your preferred technique? AB: apical bullectomy; B: bullectomy; P: pleurectomy; PA: pleural abrasion; TP: talc pleurodesis.

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Figure 4.

What is your preference for drains and chest radiographs?

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Figure 5.

What are your observed chronic pain and recurrence rates?

Discussion

Surgical intervention in pneumothorax is proven to be beneficial because it reduces morbidity and recurrence rates.^5,6 Despite this, the questions of to whom and when surgery should be offered are still debatable. This study aimed to determine the current practice of cardiothoracic surgeons in Great Britain and Ireland. The majority of consultants in the United Kingdom are offering surgery for pneumothorax based on indications that are not dissimilar to those listed in the BTS 2010 guidelines (Table 2).

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Table 2.

The British Thoracic Society guidelines: indications for pneumothorax surgery.

Indication	Additional factor
Second ipsilateral pneumothorax	Spontaneous hemothorax
First contralateral pneumothorax	Professions at risk (pilots, divers)
Synchronous bilateral spontaneous pneumothorax	Pregnancy
Persistent air leak or failure of lung reexpansion	Patient choice

According to some reports, surgery may be worth considering for people going on holiday or living far away or in places difficult to reach, due to the high (up to 54%) incidence of recurrence during the first year. ⁷ Improvements in computed tomography imaging over time and the ability to objectively detect lung disease including lung bullae have given some consultants the required mandate to intervene early. The patient’s profession and preference for surgery are considered carefully in the decision-making process, hence a number of index unilateral pneumothoraces are treated with surgery. The definition of persistent air leak and/or persistent lung collapse is different in the BTS 2010 guidelines and the American Thoracic Society 2001 guidelines. The former defined air leak and/or lung collapse beyond day 5 to 7 as persistent, whereas the latter defined it as beyond day 4.^1,2 Secondary spontaneous pneumothorax may require even earlier surgical intervention because it is less-well tolerated than primary spontaneous pneumothorax, due to preexisting lung disease in these patients. Hence the persistence of air leak and/or lung collapse beyond 48 h is recommended to have a surgical input. ⁸ The American Thoracic Society 2001 guidelines firmly recommend surgery for management of an index secondary spontaneous pneumothorax because there is huge concern about the potential lethality of a recurrence of secondary spontaneous pneumothorax. ²

The objectives of pneumothorax surgery are twofold: obliteration of offending lesions (bullae, blebs, visceral pleura porosities) and creation of symphysis between opposing pleural surfaces in order to prevent recurrence. These objectives are achievable via various techniques such as open thoracotomy, a transaxillary minithoracotomy, and VATS procedures. Surgeons historically preferred surgical pleurodesis through abrasion, however, pleurectomy has emerged as slightly more advantageous, especially in preventing recurrence. Open thoracotomy procedures have been shown via meta-analyses to have a lower recurrence rate compared to VATS procedures.^2,5 Open procedures have a recurrence rate of 1% which is lower than the 5% of VATS procedures, but the more invasive nature of open procedures results in greater blood loss, more postoperative pain, and longer hospitalization.^9,10 In addition, VATS pneumothorax surgery is more cost-effective than open procedures including minithoracotomies.^11,12 In this study, surgeons in the UK and Ireland had a unanimous preference for VATS pneumothorax procedures. Reduction in cost, fewer immediately postoperative complications, and refinement in VATS training have contributed to this preference. However, VATS access for pneumothorax surgery varies among surgeons; the majority would use a multi-portal rather than a uniportal approach, according to this study. Superiority of one over the other has not been established because there are no good-quality clinical trials comparing these approaches. A recent meta-analysis of the literature, involving 4635 patients, concluded that uniportal access is superior to multi-portal access, and the benefits observed include reduced postoperative pain, blood loss, drainage time, and postoperative hospitalization. ¹³ This study did not include pneumothorax surgery patients exclusively, and therefore, no recommendations could be made regarding VATS surgical access. For professionals such as pilots, the authors would like to enquire which operation would be required by their occupational health authority; VATS talc pleurodesis may not be acceptable to an airline that may have open thoracotomy and pleurectomy as a mandatory requirement.

In the American Thoracic Society 2001 guidelines, the parietal abrasion technique was regarded as the optimal pneumothorax intervention. ² Almost a decade later, in the BTS 2010 guidelines, the advantage of parietal pleurectomy over pleural abrasion was acknowledged, and combining both of these procedures seems relevant to achieve the full benefit of pneumothorax surgery. ¹ Johariford and colleagues ¹⁴ published a retrospective comparative study on 52 children in 2017, which highlighted a significantly reduced recurrence rate of primary spontaneous pneumothorax after pleurectomy compared to pleural abrasion. In our survey, we noted that the procedure of choice for most surgeons is bullectomy + pleurectomy, concurring with the recommendations in the BTS guidelines. A quarter of respondents prefer the combination of apical bullectomy + parietal pleurectomy + pleural abrasion. Some surgeons indicated that they observe better results after a total parietal pleurectomy including diaphragmatic abrasion. Talc remains the chemical pleurodesis agent of choice. More than a quarter of consultant surgeons in this study use talc in their patients. This could be talc pleurodesis alone, which is mainly reserved for patients with underlying lung disease, or in combination with other procedures such as pleurectomy, bullectomy, or pleural abrasion. Patient choice and age are also considered in pneumothorax management; younger patients are deemed to benefit more from surgical mechanical pleurodesis. Complications associated with the use of talc were also raised. Dangerous early inflammation, acute respiratory distress syndrome, empyema alongside late talc granulomas, lung fibrosis, silicosis, and serious pleural diseases deter some consultants from using this agent. The BTS guidelines recommend the use of sterile graded talc to prevent talc-related acute respiratory distress syndrome and empyema. The true figures for late complications of talc use are unknown because there are no long-term large case-control studies evaluating this phenomenon.

The drainage approach after pneumothorax surgery showed considerable variation among surgeons. All of them utilize an apical chest tube, and 16% use a second basal tube, especially in complex pleural conditions including hemopneumothorax; 85% of respondents use suction after pneumothorax surgery. Some consultants use clinical parameters (air leak and ability to cough) as a guide for the duration of suction needed, whereas others use chest radiographs (presence of pneumothorax and inadequate lung expansion) for this purpose. A small percentage routinely employ suction in the postoperative period regardless. Ayed and colleagues ¹⁵ demonstrated that use of suction in post-pneumothorax surgery patients is associated with a statistically significant prolongation of air leak, resulting in longer chest drainage duration and delayed hospital discharge. The role of suction in the management of post-pneumothorax surgery patients is inconclusive, and future studies are required to evaluate this. More than half of respondents keep the chest tubes in for at least 48 h, but a few may remove them earlier. Digital drainage systems were commended and recommended by the majority of respondents. The ability to provide accurate data regarding air leak and drain output enables surgeons to make drain removal decisions. This in turn facilitates earlier hospital discharge. This is a global agreement; a number of studies have also highlighted the benefits of digital drainage systems.^16–18 Although technologically advanced digital drainage systems may appear expensive, in reality, they can reduce the length of stay and number of chest radiographs per patient, resulting in an overall cost reduction. ¹⁹

There is a spectrum of practice, depending on surgeons’ preference, for imaging after pneumothorax surgery. Most surgeons in this study prefer to obtain serial chest radiographs after surgery. A number of consultants obtain chest radiographs after surgery only in the presence of clinical indications (persistent significant air leak, respiratory distress, surgical emphysema). A few surgeons would not obtain chest radiographs after removal of the chest tubes. There is no official recommendation for chest radiographs after removal of chest tubes, but the greatest importance of a chest radiograph in this scenario is in the ability to detect a residual apical space, which is an important predictor of future ipsilateral pneumothorax recurrence. ²⁰

Patients are not subjected to long-term follow-up after pneumothorax surgery, hence the precise rate of chronic pain is essentially unknown; a range of 0%–5% was given in this survey. This figure is lower than the 31.7% quoted by Passlick and colleagues. ²¹ The pneumothorax recurrence rate after surgery was in the range of 0%–3% which is close to the rate published in the BTS guideline. ¹ According to respondents, the recurrence rate was higher in patients taking nonsteroidal antiinflammatory drugs in the perioperative period, or with an inexperienced surgeon, poor surgical technique, ineffective method of pleurodesis, or chest drains removed incorrectly. As a result, the rate of chronic pain and recurrence of pneumothorax are not accurately known.

This survey has demonstrated some degree of variability in the surgical management of pneumothorax among surgeons across the UK. Despite these variations, surgeons unanimously use VATS as the intervention of choice for pneumothorax surgery, and there is also a shift towards early surgical intervention. Patient-centered care is evident when the decision for surgery is made. Digital drainage systems have also influenced practice significantly in terms of providing effective postoperative monitoring. Surgeons acknowledge that bullectomy alone provides suboptimal pneumothorax surgical management. Talc remains the chemical pleurodesis agent of choice, but concerns regarding its use deter its widespread use. Since the publication of the BTS 2010 guidelines on pneumothorax management, no other national guidelines have been published, and there is also a paucity of high-quality studies evaluating various aspects of surgical pneumothorax management. We believe these studies are vital to improve our understanding and future surgical management of pneumothorax.