Kim In Sub, Kim Jae Jun, Han Jung Wook, Jeong Seong Cheol, Kim Yong Hwan
Department of Thoracic and Cardiovascular Surgery, Uijeongbu St. Mary's Hospital, The Catholic University of Korea College of Medicine, Uijeongbu-si, Gyeonggi-do, Republic of Korea.
J Thorac Dis. 2020 May;12(5):2459-2466. doi: 10.21037/jtd.2020.03.52.
Although recurrence is included in surgical indications, there is no definitive guideline for managing recurrent spontaneous pneumothorax (SP) according to characteristics of recurrence, such as the type [primary SP (PSP) or secondary SP (SSP)] and recurrence-free interval (RFI). Actually, some patients with early cessation of air leak after closed thoracostomy tubes, a long RFI, or medical comorbidities are often managed conservatively without surgery. However, the validity of this management is unclear. The aims of the present study are to analyze treatment outcomes for recurrent SP according to the type of SP and RFI, and to check the validity of conservative treatment for patients according to type of SP and RFI.
We included 1,250 consecutive cases (624 right sided and 626 left side cases for the first episode) who were hospitalized and treated from January 2012 to June 2018. To investigate recurrence according to treatment modality (surgical or conservative treatment), we estimated RFI in each group during the observation period. RFI was measured from the completion of treatment to recurrence or last follow-up. We divided patients into two groups [the early (EG) and the late (LG) recurrence group] according to 1-year. Recurrence was defined as a subsequent episode of an ipsilateral SP, while a contralateral SP was regarded as an independent case in the present study. RFI between subgroups was compared using the Kaplan-Meier method with the log-rank test. A P value less than 0.05 (two-sided) was regarded as statistically significant.
Recurrence occurred in 47 cases after surgical intervention for the first episode (585 cases). Recurrence occurred in 265 cases after conservative treatment for the first episode of SP (665 cases). For the first episode, the surgical group (SG) had a significantly longer RFI than the conservative group (CG), regardless of the type (both, P<0.001). Conservative treatment and surgical intervention for the second episode after conservative treatment for the first episode were performed in 98 and 167 cases, respectively. For the second episode after conservative treatment for the first episode, SG also had a significantly longer RFI than CG, regardless of the types (PSP P<0.001, SSP P=0.031). To check the validity of conservative treatment for patients with a long RFI, we analyzed recurrence by dividing patients into two groups according to one-year RFI. For PSP, the early recurrence group (EG, RFI ≤1 year) had 99 cases and the late recurrent group (LG, RFI >1 year) had 67 cases. SG had a significantly longer RFI than CG in both EG and LG (EG, P<0.001 and LG, P=0.001). In addition, for SSP, there were 67 cases of EG and 32 cases of LG, SG had significantly longer RFIs than CG in EG (P=0.007). However, there was no significant difference in RFI between SG and CG in LG (P=0.748).
The present study revealed diversity of management outcomes according to characteristics of recurrence and provides some evidences of the validity of conservative treatment in recurrent SSP with a long RFI. Further large-scale prospective randomized trials are required to validate these findings.
虽然复发被纳入手术指征，但对于复发性自发性气胸（SP），尚无根据复发特征（如类型[原发性SP（PSP）或继发性SP（SSP）]和无复发间隔时间（RFI））进行管理的明确指南。实际上，一些在胸腔闭式引流管拔除后漏气早期停止、RFI长或有内科合并症的患者常采用保守治疗而非手术治疗。然而，这种治疗方法的有效性尚不清楚。本研究的目的是根据SP的类型和RFI分析复发性SP的治疗结果，并根据SP的类型和RFI检查对患者进行保守治疗的有效性。
我们纳入了2012年1月至2018年6月期间住院治疗的1250例连续病例（首次发作时624例右侧和626例左侧）。为了根据治疗方式（手术或保守治疗）研究复发情况，我们在观察期内估计了每组的RFI。RFI从治疗结束到复发或最后一次随访进行测量。根据1年时间，我们将患者分为两组[早期（EG）和晚期（LG）复发组]。复发定义为同侧SP的后续发作，而对侧SP在本研究中被视为独立病例。使用Kaplan-Meier方法和对数秩检验比较亚组之间的RFI。P值小于0.05（双侧）被认为具有统计学意义。
首次发作接受手术干预后有47例复发（共585例）。首次发作SP接受保守治疗后有265例复发（共665例）。对于首次发作，无论类型如何，手术组（SG）的RFI均显著长于保守组（CG）（均P<0.001）。首次发作保守治疗后第二次发作接受保守治疗和手术干预的分别有98例和167例。对于首次发作保守治疗后的第二次发作，无论类型如何，SG的RFI也显著长于CG（PSP，P<0.001；SSP，P=0.031）。为了检查对RFI长的患者进行保守治疗的有效性，我们根据1年RFI将患者分为两组分析复发情况。对于PSP，早期复发组（EG，RFI≤1年）有99例，晚期复发组（LG，RFI>1年）有67例。SG在EG和LG中的RFI均显著长于CG（EG，P<0.001；LG，P=0.001）。此外，对于SSP，EG有67例，LG有32例，SG在EG中的RFI显著长于CG（P=0.007）。然而，LG中SG和CG的RFI无显著差异（P=0.748）。
本研究揭示了根据复发特征管理结果的多样性，并为RFI长的复发性SSP保守治疗的有效性提供了一些证据。需要进一步的大规模前瞻性随机试验来验证这些发现。
