Video Assisted Thoracic Surgery (VATS) is considered the gold standard surgical technique for the treatment of pneumothorax. To resect blebs or bullae and to achieve satisfactory pleurodesis, several techniques have been described. Minimally invasive technique using staplers to remove bullous parenchyma is the popular method by the majority of thoracic surgeons. Other techniques to perform bullectomy include endoscopic suturing [2] [3] ; endoloop ligation [2] [4] and cautery [5] [6] have been described in the literature. The same is true for pleurodesis as there are different ways described including Talc poudrage [7] [8] , pleural abrasion [5] [9] [10] , partial pleurectomy [6] [11] [12] and pleural argon beam coagulation [13] . There are no studies comparing these different ways of pleurodesis to decide which is better and it remains a department preference in choosing which method. Published studies regarding post-operative morbidity and mortality are lacking. We decided to review our current morbidity and mortality using VATS for the management of primary spontaneous pneumothorax in order to better understand the complications of this procedure, identify any risk factors for complications and see if there is any way for avoiding them.

Spontaneous pneumothorax (SP) is one of the common problems that the thoracic surgeon face in his or her practice. The rate of recurrence is 20% after a first episode, 60% after a second, and 80% after a third [14] . When spontaneous pneumothorax occurs, it is initially treated by chest tube insertion. Surgery is reserved for cases of recurrence or prolonged air leak. It is also considered when pneumothorax occurs in persons with high- risk occupations, such as deep sea divers or airline pilots, patients with tension pneumothorax or a hemopneumothorax. In these cases, it might be scheduled as well to treat the first episode in order to prevent recurrences [15] .

The traditional operation was by limited thoracotomy using axillary or posterolateral approach. Currently, VATS has been increasingly used. There was always a controversy regarding the best treatment, either to manage surgically by open or VATS techniques.

Evidence from randomized controlled trials regarding the advantages associated with VATS for the treatment of pneumothorax seems to be similar for other advantages associated with other minimally invasive thoracic surgeries for other reasons. Most of these studies reported less surgery time, lower use of pain medication, and lower length of hospital stay [16] .

Horio et al. found that patients operated on with VATS had higher recurrences compared to patients operated on with thoracotomy. They suggested that these differences could be explained by undetected bullae in the VATS group [17] . Compared to thoracotomy, air leakage tests are more technically challenging during VATS.

Other authors have also recommended wedge resection of the apex in all cases [18] even if the bullae or bleb is not found. Wedging of the lung apex will lead to the creation of inflammation that leads to adhesions between the lung and the thoracic wall.

In a recent multicenter cohort study, they reported successful video assisted thoracic surgery for pneumothorax in 714 patients over a period of two years [19] . Hatz et al. reported excellent short and long term results comparable with thoracotomy [20] .

In a review about the recurrence rate of pneumothorax with randomized and non-randomized trials, Barker et al. report that the recurrence of pneumothorax, when the same pleurodesis procedure is performed, is four-fold increased after VATS approaches rather than open approaches [21] . Different results were previously published by Sawada et al. who did not observe a statistical difference between videothoracoscopy and thoracotomy [22] . In our review the rate of recurrent pneumothoraces was 7.4%.

In the literature review there were some postoperative cases of death reported [23] . They were not consequences of VATS technique, but they were directly correlated to the poor preoperative conditions of the patients. In our study there were no death reported.

Bleeding requiring reoperation has been reported by some authors [2] [3] , but the source of blood loss was undetectable in the majority of the cases. In our experience there were one hemothorax which subsided by its own and didn’t require surgical intervention.

It must be underlined that, besides cases of re-operation, all authors report prolonged air leak, which is the most common postoperative complication. Other morbidities reported in literature are: pneumonia, atelectasis, needing of mechanical ventilation, wound infections, empyema, pleural effusion, ARDS and Horner’s syndrome [24] [25] .

Uramoto et al. [26] reported factors that predict recurrence. Smoking cessation has been associated with a decreased risk of recurrent SP over a follow-up period of several years. Second, the postoperative recurrence rate was higher in patients with comorbidities than in those without. Third, a history of previous surgery for ipsilateral SP was associated with a higher rate of recurrence. Finally, the postoperative recurrence rate was higher in the patients who underwent hand stitching for blebs than those who underwent device-driven repair [26] .

In a recent review jean-Philippe Delpy et al. on 7647 patients in France hospitals to detect the prognostic factors influencing postoperative complications for spontaneous pneumothorax [27] , they found that factors associated with the occurrence of respiratory complications (which are defined as atelectasis, pneumonia, empyema, prolonged ventilation, acute respiratory distress syndrome and prolonged air leaks) are male gender, patients older than 33 years, smokers, ASA score of ≥2 and patients with a history of pulmonary disease, coronary artery disease, peripheral artery disease and thoracic surgery. Respiratory complications also occurred more frequently on the right side. The median time to recurrence was 3 months (range: 1 - 76 months).

To evaluate the quality of life after surgical treatment of pneumothorax Ben-Nun et al. compared VATS and limited thoracotomy. They observed that patients in the thoracotomy group needed significantly higher doses of narcotic analgesia for a longer period than patients in the VATS group [10] . Similarly Balduyck et al. in a recent prospective study have demonstrated that VATS has an improved thoracic pain evolution than antero-lateral thoracotomy. They also report a significant difference one month postoperatively between VATS and open surgery in physical, role and cognitive functioning and dyspnea in favor of VATS.

The recurrence rate after VATS treatment for pneumothorax was very low (between 0% and 5.8%) [12] .

Chronic pain and chest wall paresthesia one year after the procedure have been reported in about 21% of the patients [9] [28] . Particularly in those who underwent pleurectomy. In order to avoid these complications, Jutley et al. [29] propose the uniportal VATS technique, but the study is limited by the short follow up and by the small number of cases. Chan et al. have suggested the use of needle scopic instruments which, compared with the conventional ones, reduce the residual neuralgia [14] . Long-term results of VATS treatment of pneumothorax are limited.

VATS bullectomy and pleurectomy is now the preferred surgical approach for treatment of recurrent spontaneous pneumothorax with a reasonable low recurrence rate. Prolonged air leak and the recurrence of pneumothorax are the most common post-operative complication. Smoking was found to be a risk factor for post-operative complications and therefore smoking cessation is important in improving outcome. Further studies with prospective data collection are needed to verify our results.

Ramzi A. Addas,Farid M. Shamji,Sudhir R. Sundaresan,Patrick James Villeneuve,Andrew J. E. Seely,Sebastien Gilbert,Donna E. Maziak, (2016) Is VATS Bullectomy and Pleurectomy an Effective Method for the Management of Spontaneous Pneumothorax?. Open Journal of Thoracic Surgery,06,25-31. doi: 10.4236/ojts.2016.63005