What is the recommended treatment for recurrent spontaneous pneumothorax (RSP), specifically regarding resection bullectomy and pleurodesis?

Management of Recurrent Spontaneous Pneumothorax

For recurrent spontaneous pneumothorax, thoracoscopic bullectomy combined with pleurodesis is the recommended treatment approach with success rates of 95-100% compared to 78-91% with chemical pleurodesis alone. 1

First-line Surgical Management

Indications for Surgical Intervention

• Second pneumothorax occurrence (recommended by 85% of experts) 1
• First contralateral pneumothorax 1
• Persistent air leak beyond 4 days 1
• High-risk occupations (divers, pilots, military personnel) 1
• History of tension pneumothorax 1

Preferred Surgical Approach

• Video-assisted thoracoscopic surgery (VATS) is the preferred approach 1
  • Lower postoperative decline in lung function compared to thoracotomy 1
  • Can be performed with or without video assistance
  • Shorter recovery time and less postoperative pain

Surgical Components

1. Bullectomy

   • Staple bullectomy is strongly recommended when apical bullae are visualized 1
   • Alternative techniques include electrocoagulation, laser ablation, or hand sewing based on institutional expertise 1

2. Pleurodesis

   • Should be performed in conjunction with bullectomy 1
   • Parietal pleural abrasion limited to the upper half of the hemithorax is recommended 1
   • Parietal pleurectomy is an acceptable alternative 1
   • Combined approach (bullectomy + pleurectomy + pleurodesis) showed 0% recurrence in one study 2

Alternative Approaches

Chemical Pleurodesis

• Acceptable for patients who:
  • Wish to avoid surgery 1
  • Present increased surgical risk (e.g., bleeding diathesis) 1
  • Are not considered fit for surgery 1
• Success rates of 78-91% (lower than surgical approaches) 1
• Preferred agents:
  • Doxycycline or talc slurry 1
  • Autologous blood pleurodesis for persistent air leak 1

Thoracotomy

• Consider for high-risk occupations requiring lowest possible recurrence risk 1
• Associated with greater postoperative decline in lung function 1

Efficacy and Outcomes

• Surgical interventions (bullectomy with pleurodesis) have success rates of 95-100% 1
• Chemical pleurodesis has success rates of 78-91% 1
• Fixation of the lung apex to the chest wall may further reduce recurrence rates (4.6% vs 8.7% without fixation) 3
• Presence of large bullae (>2cm) increases risk of treatment failure 4
• Younger age is associated with increased risk of recurrence 5

Potential Complications

• Prolonged air leak (>7 days) in up to 53% of cases 6
• Atrial fibrillation in approximately 12% 6
• Postoperative mechanical ventilation in 9% 6
• Pneumonia in 5% 6
• Mortality approximately 2% at 1 year 6

Special Considerations

• CT scan evaluation is recommended to assess bullae size and extent, and quality of surrounding lung parenchyma 6
• Preoperative pulmonary rehabilitation improves surgical outcomes 6
• Smoking cessation is critical for maintaining long-term benefits 6
• Follow-up should extend beyond two years as 35.7% of recurrences may present after this period 2

Algorithm for Management

1. Confirm recurrent spontaneous pneumothorax
2. Evaluate patient for surgical candidacy
3. If surgical candidate: Proceed with VATS bullectomy + pleurodesis
4. If not surgical candidate: Consider chemical pleurodesis with doxycycline or talc slurry
5. For high-risk occupations: Consider thoracotomy with pleurodesis for lowest recurrence risk
6. Provide discharge and activity advice to all patients post-pneumothorax

The evidence strongly supports surgical intervention with bullectomy and pleurodesis for recurrent spontaneous pneumothorax, with VATS being the preferred approach due to its high success rate and lower morbidity.