Although there is high chance that this patient may have psychiatric illness, it is shocking such a treatable disease lead to this tragedy. The adolescent with pneumothorax must be dissatisfied with the treatment. The recurrence must be frequent causing disruption of school and social life. With the introduction of minimally invasive thoracic surgery (also named VATS for Video assisted Thoracic Surgery), pleural disease like pneumothorax is easily treated. However, the popularity of using VATS do induce non -expert surgeons to operate more. Recurrent pneumothorax (if recur after the first attempt of surgery) do need referral to specialised experienced thoracic surgeons with keen interest in VATS.
Operations maneuvers for treating recurrence must include:
1. Proper identification of lung bleb (weakness of lung causing air leak)
2. Consideration of additional procedure like: pleurectomy, limited deocortication and adhesiolysis esp for lung adhering to medial part of diaphragm
and pleural tenting or transient phrenic nerve paralysis
3. Adding chemical agents like talc insufflation and chemical agents silver nitrate, fibrin glue and oxytetracycline , concentrated glucose
4. Position of suitable drain or drains (2 drains)
5. If patient allow and prefer early discharge, use of ambulatory draiange device or drainage bag with valve.
Proper procedure can reduce the recurrence to less than 3 %.
With patient aging beyond 35, the possiblity is low by nature. But with good surgery, if there is no recurrence in the post operative 3 - 4 years, the chance of recurremce is much less though not unheard of.
Sometime, pneumothorax cause problem of immobilisation. In old days, a young patient has open pleurodesis operation and subsequent deep vein thrombosis. He was put on anticoagulant but unfortunately develop hemothorax in recent operated chest. A redo thoracotomy is needed and patient has prolonged hospital stay.
In patient with Marfan's syndrome, recurrent hemopneumothorax may be troublesome.
By Dr Chung Shiu Shek
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