Surgical treatment for refractory spontaneous pneumothorax （experience of 16 cases）

Surgical treatment for refractory spontaneous pneumothorax （experience of 16 cases） | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Surgical treatment for refractory spontaneous pneumothorax （experience of 16 cases） Hailong Liang, Zhaofei Yan, Xuanchen Liu, Tiansheng Yan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5363903/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Recurrence is major existing problem in spontaneous pneumothorax (SP) therapy. Refractory SP refers to recurrent SP post previous VATS or pleurodesis. There is no consensus on how to treat refractory SP so as to avoid another recurrence. We introduce our experiences in reoperation for such refractory SP. Methods we retrospectively review 16 consecutive cases of refractory SP who received repeated VATS treatment in Beijing University of Chinese medicine Dongfang Hospital. Perioperative data are documented, and postoperative follow up is made, with emphasis on introducing surgical strategy and special technique established by our team, and discussing how these measures could effectively avoid recurrence. Results Among all qualified patients,15 cases had previous VATS history,1 case had previous chemical pleurodesis history. VATS therapy was performed in all cases, and was converted to thoracotomy only in 1 case due to severe thoracic callous-like adhesions. All patients recovered well and were discharged. Mean postoperative follow-up time is 15.2 months. 3 cases of recurrence happened. Among them,2 cases were cured by drainage ,1 case were cured with oxygen inhalation. Conclusions Our proposed surgical strategy and techniques may effectively treating refractory SP and prevent further recurrence. spontaneous pneumothorax refractory pneumothorax reoperation recurrence Figures Figure 1 Figure 2 Figure 3 Background Spontaneous pneumothorax (SP) is a clinically common disease. The etiology of SP is believed as rupture of bullas/blebs or emphysema-like lung tissue, then consequently leading to air leak into normally potential-existing thoracic pleural cavity ( 1 , 2 ) . For persistent air-leak ≥ 4 days or recurrent pneumothorax, there is unanimous consensus in choosing VATS(video-assisted thoracic surgery) operation as optimal therapy to cure air leakage and prevent recurrence if operation is not contraindicated or refused ( 3 , 4 ) ,the procedure usually include wedge resection of blebs/bullas or emphysema-like lung tissue and pleurodesis by various methods ༈5,6༉ . Although recurrence rate post VATS pleurodesis could be reduced to as low as 0.0%-9.4% (7–12) , it is not completely resolved yet. Once SP recurs, severe thoracic adhesions make it quite tough for surgeon to choose optimal therapy. Severe thoracic adhesions would make re-operation much more dangerous and difficult compared with initial operation. Besides, severe thoracic adhesions may result in irregular air-cavities interlinked or not suppressing adjacent lung tissue, which makes it difficult to insert draining tube into air-cavities, and lung re-expansion effect could hardly be satisfying which may be potential reason for another recurrence. Therefore, we term such SP with severe thoracic adhesions due to previous VATS or pleurodesis as “refractory SP”. Clinically there is no consensus on which kind of treatment is optimal for refractory SP to prevent another recurrence. By retrieving literature, we could find limited reports adopting different measures, including conservative observation, chest drainage and repeated VATS operation ( 10 , 13 , 14 ) . During recent years, we accumulate some experiences in reoperation for refractory SP with satisfying clinical effect. Based on these experiences, we propose that unsatisfying lung re-expansion post previous therapy and consequently improper adhesions may play an important role in SP recurrence. In this article, we retrospectively review 16 cases of refractory SP receiving reoperation in our hospital, aiming to introduce surgical strategy and special techniques gradually established by our team for such refractory SP, with emphasis on discussing how these measures could effectively prevent pneumothorax recurrence. Methods This is a retrospective study, and Institutional Ethics Committee approval is formally exempted. Informed consent were obtained from all patients enrolled in this study, and information of patients were protected. We retrospectively review 16 consecutive patients of refractory SP enrolled in Department of Thoracic Surgery, Dongfang Hospital, Beijing University of Chinese Medicine, between October 2020 and September 2024. The inclusion criteria were as follows:1.recurrent SP; 2.received VATS therapy or pleurodesis by drainage previously; 3.receive the second VTAS therapy. Detailed clinical data were collected for each patient, including gender, age, history of occupational dust exposure, smoking history, disease history, pneumothorax history and treatment before the first VATS therapy or previous pleurodesis, frequency and medical treatment for recurrent pneumothorax post the first VTAS or pleurodesis, perioperative data for the second VATS therapy, postoperative follow-up and medical treatment of recurrence post the second VATS therapy. All qualified patients received the second VATS therapy performed by the same experienced surgeon. All patients received routine preoperative examinations including chest radiography, electrocardiogram, thoracic CT scan, abdominal ultrasonography. Preoperative medical treatment is oxygen inhalation without invasive measures, such as drainage or thoracocentesis. Surgical points VATS approach was adopted for every patient, and was converted to thoracotomy only in one case due to severe thoracic callous-like adhesions. The whole process of operation could be divided into three major steps. Disassociation of adhesions: severe thoracic adhesion is inevitable because of previous VATS procedure or pleurodesis. Complete disassociation of thoracic adhesions is accomplished for every patient. If lung re-expansion is still evaluated to be less satisfying to fill whole thoracic cavity, then incision of pulmonary ligament and disassociation of hilar pleura is also performed to increase lung mobility. Resection of bullae: if bullae is detected during operation, resection with stapler is performed without covering. Multiple drainage: this is a special technique developed by our team to ensure rapid and full lung re-expansion. we design to put 4–5 draining tubes into respective corners of cone-shaped thoracic cavity, usually including thorax apex, anterolateral highest point, posterior costophrenic sinus, cardio-phrenic angle region, and sometimes posterolateral highest point(Fig. 1 ). Postoperative chemical pleurodesis: Complete postoperative lung re-expansion confirmed by thoracic CT scan and no air leak are two essential prerequisites for performing repeated pleurodesis via chest tubes. The agent we used for chemical pleurodesis is 50% glucose mingled with iodophor. All patients recovered well and were discharged. Then they received periodic check, and were followed up till now. Statistical analysis The data are presented as mean or mean ± SD. In order to identify possible hazard factor for pneumothorax recurrence post the second VATS, we made Logistic regression analysis taking several factors into account, including age, gender, resection of bulla or not, existence of persistent air leak post the second VATS. Statistical analysis is performed using SPSS Version 25 software (SPSS, Chicago, IL, USA). Results The average age of 16 qualified patients is 31.7 ± 15.3 years old. None of them complain history of smoking and occupational dust exposure. Detailed clinical information of patients’ previous VATS therapy or pleurodesis,and previous pneumothorax history are summarized in Table 1 . Among them,15 cases had history of previous VATS,1 case had previous repeated drainage and chemical pleurodesis by erythromycin. 3 cases had history of previous contralateral pneumothorax which were cured respectively by drainage or VATS. Clinical information for patients’ pneumothorax recurrence post their previous VATS or chemical pleurodesis are summarized in Table 2 , including recurrence frequency ,medical treatment, etc. Among them,3 cases received chemical pleurodesis after recurrence post the first VATS, 2 cases by erythromycin, and 1 case by thrombin. Perioperative information for patients’ second VATS procedure are summarized in Table 3 , including operation duration time, blood loss, etc. All patients had severe thoracic adhesions, and most adhesions were in improper position which is named by us as ectopic adhesion(detailed explanation is mentioned below). Clinical information of follow-up and recurrence treatment post the second VATS therapy are summarized in Table 4 . Among all patients,3 cases of recurrence happened.2 cases were cured by drainage ,1 case were by observation(oxygen inhalation). Table 1 Clinical information of patients’ first VATS therapy or pleurodesis and previous pneumothorax history Clinical information Frequency / Case Pneumothorax frequency * 2.3 ± 1.3 Medical treatment # Observation & 7 thoracentesis 0 drain 16 Bulla resection ∮ Yes 15 No 1 Pleurodesis ★ chemical 5 mechnical 11 * average pneumothorax frequency before the first VATS therapy. & observation means oxygen inhalation. # information of medical treatment for pneumothorax before the first VATS(case-time). ∮information of the first VATS. ★Pleurodesis during the first VATS or by drainage. Table 2 Clinical information of pneumothorax recurrence post patients’ first VATS therapy or pleurodesis Clinical information Case/time Frequency # 1.5 ± 0.96 Medical treatment observation 11 thoracentesis 0 drain 7 Chemical pleurodesis Yes 3 No 13 #average recurrence frequency. Table 3 Perioperative information for patients’ second VATS therapy Perioperative information Data Time(minute) 203.7 ± 76.46 Blood loss(ml) 78 ± 10.88 Draining tubes 4.8 ± 0.42 Bulla resection Yes 14 No 2 Draining tube adjustment Yes 4 No 12 Persistent air leak* Yes 6 No 10 Vacuum suction Yes 6 No 10 Chemical pleurodesis 3 times 8 4 times 8 *postoperative air leak lasting more than 5 days is defined as persistent air leak Table 4 Follow-up information and recurrence treatment post the second VATS therapy Follow up information Data Recurrence Yes 3 No 13 Medical treatment observation 1 Drain 2 Time (month)* 15.2 ± 8.3 *means follow up time. Discussion SP is a relatively common disease of clinic significance. According to whether or not patients have underlying lung disease, SP is divided into primary spontaneous pneumothorax (PSP) and secondary spontaneous pneumothorax (SSP) ( 15 ) . Till now, worldwide epidemiology study of SP is lacking. Several large-scale studies could be retrived which are based on data from French national dataset ( 16 ) , Korea National Sample Cohort (NSC) ( 17 ) , England General Practice Research Database (GPRD) ( 18 ) .The authors report an annual rate of SP of 19.2–66 per 100 000 population, with a male-to-female ratio of approximately 3.3–10:1. More specifically, prevalence rate of PSP is estimated to account for 14–50% of SP annual prevalence rate. Clinically recurrence rate of SP is as high as 17–49% (19–21) . Therefore, operation is recommended for recurrent SP or the first episode of SP with persistent air leak lasting more than 5–7 days. Since the pathogenesis of SP generally arises from rupture of bleb/bulla or emphysema-like lung tissue, the whole procedure usually includes 2 major steps, namely resection of bullas and mechanical/chemical pleurodesis. However, the vexed problem of relapse is not completely resolved yet. As mentioned above, recurrent pneumothorax post previous VATS or pleurodesis is refractory and challenging to decide further therapy since presently it is difficult to totally prevent recurrence. The reason for postoperative pneumothorax recurrence is uncertain. Maria et al made large-scale retrospective study on patients of PSP who received treatment by VATS procedure, aiming to identify risk factors for postoperative pneumothorax recurrence. They analyzed different methods of pleurodesis and other clinical factors, and concluded that only prolonged postoperative air leak was independent risk factor for pneumothorax recurrence post VATS treatment, while different methods of pleurodesis did not have significant impact on recurrence ( 22 ) . Andrea et al made similar study with consistent conclusion, moreover, they also identified female-gender was another independent risk factor for pneumothorax recurrence post VATS treatment ༈23༉ . During recent years, we accumulate some experiences in treating such refractory SP, then propose that unsatisfying lung re-expansion at early stage postoperatively is an important reason for later recurrence. In a way our viewpoint is consistent with previous studies.To illustrate, we introduce an important concept of ectopic adhesion which has not been proposed before, namely some part of lung parenchyma does not attach to its usually attached parietal pleura when in natural state of full expansion due to insufficient lung re-expansion at early stage postoperatively commonly seen in clinical practice. Then under effect of pro-adhesion factors, such as chemical irritation or mechanical abrasion, so that improper thoracic adhesion is easy to form. Obviously such ectopic adhesion would impede lung natural expansion to fill thoracic cavity, so that over-expansion of other part of lung parenchyma is needed as one of compensatory measures to fill residual thoracic cavity(Fig. 2 A-C). Theoretically ectopic adhesion would exert extra negative pressure on lung parenchyma to neutralize traction by over expansion, thus new pulmonary emphysema and bullae/bleb could gradually form under effect of such persistent negative pressure. This situation is similar to that in lung apex where usually the highest negative pressure exists and bullae/bleb is easy and the most often to form. Our proposed theory might explain why pneumothorax recur post wedge resection and pleurodesis. Based on our proposed theory, we gradually establish surgical strategy and special technique in refractory pneumothorax therapy with satisfying clinical effect. Firstly, postoperative recurrent pneumothorax usually exhibit irregular air cavities in thoracic CT scan image due to severe adhesions caused by previous treatment. According to our experience, thoracic adhesions in most cases are ectopic adhesion. Therefore, fully disassociation of thoracic adhesion is indispensable and the most difficult step of re-operation for refractory pneumothorax. If tight adhesion between lung and major vessel is detected(Fig. 2 D), disassociation by VATS would be dangerous and challenging for surgeon. Considering principle of safety priority, proper expansion of incision is sometimes advisable. Besides, formation of fibrous layer covering lung parenchyma is also common due to previous pleurodesis. Theoretically fibrous layer could be a hampering factor for lung full expansion. If possible, stripping of fibrous layer is recommended. Nevertheless, it is unwise to strip fibrous layer tightly attached to lung parenchyma, otherwise excessive lung injury would be disastrous for lung expansion. According to our experience, fibrous layer might delay lung expansion. However, it is certain that lung parenchyma limited by fibrous layer is still able to gradually expand to fill residual thoracic cavity in existence of sufficient drainage. Sometimes hilar pleura is also disassociated to release more lung mobility so as to ensure lung postoperative expansion sufficient to fill thoracic cavity. Secondly, multi-tube drainage is a special surgical technique developed by us to ensure lung re-expansion at early stage postoperatively and avoid ectopic adhesion. The Rationale is utilizing chest tube drainage as pulling force so as to ensure lung natural and full expansion (Fig. 3 A). Since lung re-expansion could hardly be satisfying at early stage postoperatively because of insufficient breath depth due to pain. Moreover, since lung volume is often reduced due to previous wedge resection, it could be another unfavorable factor for lung expansion to fill thoracic cavity. Considering it is quite prone to form new adhesions in thoracic cavity after disassociating severe adhesions, rapid re-expansion is crucial for avoidance of new ectopic adhesions. Therefore, we design to put several draining tubes into corners of thoracic cavity, thereby pulling lung to expand outwards, similar to pulling four corners of a sail to keep it outspread(Fig. 3 B). According to our experience, these draining tubes are particularly useful to lead lung to re-expand naturally. To our knowledge, this technique has not been reported before. Thirdly, final step is to perform repeated chemical pleurodesis via chest tubes. We emphasize that complete lung re-expansion confirmed by postoperative thoracic CT scan and no air leak are two essential prerequisites for performing pleurodesis. The agent we used for pleurodesis is usually 50% glucose mingled with iodophor. The purpose of pleurodesis is to generate diffuse thoracic adhesions so as to seal thoracic cavity which could effectively avoid recurrence in spite of formation of new bullae/bleb detected by others in such recurrent pneumothorax ( 24 ) . By these measures, all patients included in this study achieved satisfying clinical effect. In future, large scale prospective study is needed to further evaluate efficacy of these measures in reducing refractory pneumothorax recurrence. Conclusions Insufficient lung expansion post operation due to improper ectopic adhesions may play important role in pneumothorax recurrence. Our special technique utilizing outwards drainage to achieve satisfying lung re-expansion at early stage postoperatively based on fully disassociation of thoracic adhesions could effectively avoid ectopic adhesions, which is crucial for prevention of refractory pneumothorax postoperative recurrence. Abbreviations SP for Spontaneous pneumothorax; PSP for primary spontaneous pneumothorax; SSP for secondary spontaneous pneumothorax; VATS for video-assisted thoracic surgery; Declarations Ethics approval and consent to participate This is a retrospective study, informed consent to participate were obtained from all patients, and patients’ information are fully protected. Ethics approval and consent is formally waived by Ethics Committee of Beijing University of Chinese Medicine Dongfang Hospital according to latest Chinese national biologic research ethical guideline . Consent for publication: not applicable. Availability of data and materials Data sharing is not applicable to this article as no datasets were generated or analysed during the current study. Competing interests The authors declare that they have no competing interests. Funding:No Authors' contributions: Hailong Liang is in charge of data procession, draft writing and submission; Tiansheng Yan is in charge of study design, manuscript review; Zhao fei Yan is in charge of data collection. Xuanchen Liu is in charge of data collection. Acknowledgements: not applicable. Authors' information Professor Tiansheng Yan is a famous thoracic surgeon in China with great reputation in field of complex spontaneous pneumothorax surgical therapy. References de Hoyos A, Fry WA. Chapter 58: Pneumothorax. In: Shields TW, LoCicero J, Reed CE, Feins RH, eds. General Thoracic Surgery. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2009:739-62. Lesur O., Delorme N., Fromaget J. M., Bernadac P. ,Polu J. M. Computed tomography in the etiologic assessment of idiopathic spontaneous pneumothorax. Chest, 1990,98:341–347. Baumann MH, Strange C, Heffner JE, Light R, Kirby TJ, Klein J, et al. 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Cattoni M, Rotolo N, Mastromarino MG, Cardillo G, Nosotti M, Mendogni P, et al. Analysis of pneumothorax recurrence risk factors in 843 patients who underwent videothoracoscopy for primary spontaneous pneumothorax: results of a multicentric study. Interact CardioVasc Thorac Surg 2020;31:78–84. Imperatori A, Rotolo N, Spagnoletti M, Festi L, Berizzi F, Di Natale D ,et al. Risk factors for postoperative recurrence of spontaneous pneumothorax treated by video-assisted thoracoscopic surgery. Interact CardioVasc Thorac Surg 2015;20:647–53. Cho S, Jheon S, Kim DK, Kim HR, Huh DM, Lee S, et al. Results of repeated video-assisted thoracic surgery for recurrent pneumothorax after primary spontaneous pneumothorax. Eur J Cardiothorac Surg 2018;53:857–61. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5363903","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":376248125,"identity":"fd4dbc05-797c-4d82-9098-c19be1527d50","order_by":0,"name":"Hailong Liang","email":"","orcid":"","institution":"Beijing University of Chinese medicine","correspondingAuthor":false,"prefix":"","firstName":"Hailong","middleName":"","lastName":"Liang","suffix":""},{"id":376248126,"identity":"692361f0-9e32-4257-8237-0c8d04c896aa","order_by":1,"name":"Zhaofei Yan","email":"","orcid":"","institution":"Beijing University of Chinese 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region;\u003c/p\u003e\n\u003cp\u003ed: thorax apex;\u003c/p\u003e\n\u003cp\u003ee: posterolateral highest point;\u003c/p\u003e\n\u003cp\u003eB: operative distribution of draining tubes\u003c/p\u003e\n\u003cp\u003ea: draining tube placed in anterolateral highest point;\u003c/p\u003e\n\u003cp\u003eb: draining tube placed in posterior costophrenic sinus;\u003c/p\u003e\n\u003cp\u003ec: draining tube placed in cardio-phrenic angle region;\u003c/p\u003e\n\u003cp\u003ed:draining tube placed in thorax apex;\u003c/p\u003e\n\u003cp\u003ee: draining tube placed in posterolateral highest point;\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-5363903/v1/05295ea723c2461fd9323749.png"},{"id":70507225,"identity":"3b5f33dc-d483-4c4a-abf6-57b204d5f43c","added_by":"auto","created_at":"2024-12-03 23:51:20","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2289934,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-5363903/v1/3cb5a4679696a33de289b703.png"},{"id":70507900,"identity":"47005a66-ae1f-498b-b610-0fc9f15eb824","added_by":"auto","created_at":"2024-12-03 23:59:20","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1768003,"visible":true,"origin":"","legend":"\u003cp\u003erationale of utilizing draining tubes to pull lung to expand outwards\u003c/p\u003e\n\u003cp\u003eA:illustration of respective draining tubes pulling lung in illustrated directions to expand;\u003c/p\u003e\n\u003cp\u003eB: pulling corners of sail to keep outspread；\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-5363903/v1/90fda5648ebe255163b64edc.png"},{"id":74909283,"identity":"ad352abd-2efe-4f8b-9d4c-5457d5978f13","added_by":"auto","created_at":"2025-01-28 08:47:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5681451,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5363903/v1/05c0acca-4bfe-4a0a-bbaf-b8ae9e455c00.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Surgical treatment for refractory spontaneous pneumothorax （experience of 16 cases）","fulltext":[{"header":"Background","content":"\u003cp\u003eSpontaneous pneumothorax (SP) is a clinically common disease. The etiology of SP is believed as rupture of bullas/blebs or emphysema-like lung tissue, then consequently leading to air leak into normally potential-existing thoracic pleural cavity\u003csup\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/sup\u003e. For persistent air-leak ≥ 4 days or recurrent pneumothorax, there is unanimous consensus in choosing VATS(video-assisted thoracic surgery) operation as optimal therapy to cure air leakage and prevent recurrence if operation is not contraindicated or refused\u003csup\u003e(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/sup\u003e,the procedure usually include wedge resection of blebs/bullas or emphysema-like lung tissue and pleurodesis by various methods\u003csup\u003e༈5,6༉\u003c/sup\u003e. Although recurrence rate post VATS pleurodesis could be reduced to as low as 0.0%-9.4% \u003csup\u003e(7–12)\u003c/sup\u003e, it is not completely resolved yet.\u003c/p\u003e \u003cp\u003eOnce SP recurs, severe thoracic adhesions make it quite tough for surgeon to choose optimal therapy. Severe thoracic adhesions would make re-operation much more dangerous and difficult compared with initial operation. Besides, severe thoracic adhesions may result in irregular air-cavities interlinked or not suppressing adjacent lung tissue, which makes it difficult to insert draining tube into air-cavities, and lung re-expansion effect could hardly be satisfying which may be potential reason for another recurrence. Therefore, we term such SP with severe thoracic adhesions due to previous VATS or pleurodesis as “refractory SP”. Clinically there is no consensus on which kind of treatment is optimal for refractory SP to prevent another recurrence.\u003c/p\u003e \u003cp\u003eBy retrieving literature, we could find limited reports adopting different measures, including conservative observation, chest drainage and repeated VATS operation\u003csup\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/sup\u003e. During recent years, we accumulate some experiences in reoperation for refractory SP with satisfying clinical effect. Based on these experiences, we propose that unsatisfying lung re-expansion post previous therapy and consequently improper adhesions may play an important role in SP recurrence. In this article, we retrospectively review 16 cases of refractory SP receiving reoperation in our hospital, aiming to introduce surgical strategy and special techniques gradually established by our team for such refractory SP, with emphasis on discussing how these measures could effectively prevent pneumothorax recurrence.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003e This is a retrospective study, and Institutional Ethics Committee approval is formally exempted. Informed consent were obtained from all patients enrolled in this study, and information of patients were protected. We retrospectively review 16 consecutive patients of refractory SP enrolled in Department of Thoracic Surgery, Dongfang Hospital, Beijing University of Chinese Medicine, between October 2020 and September 2024. The inclusion criteria were as follows:1.recurrent SP; 2.received VATS therapy or pleurodesis by drainage previously; 3.receive the second VTAS therapy. Detailed clinical data were collected for each patient, including gender, age, history of occupational dust exposure, smoking history, disease history, pneumothorax history and treatment before the first VATS therapy or previous pleurodesis, frequency and medical treatment for recurrent pneumothorax post the first VTAS or pleurodesis, perioperative data for the second VATS therapy, postoperative follow-up and medical treatment of recurrence post the second VATS therapy. All qualified patients received the second VATS therapy performed by the same experienced surgeon.\u003c/p\u003e\u003cp\u003eAll patients received routine preoperative examinations including chest radiography, electrocardiogram, thoracic CT scan, abdominal ultrasonography. Preoperative medical treatment is oxygen inhalation without invasive measures, such as drainage or thoracocentesis.\u003c/p\u003e\u003cp\u003eSurgical points\u003c/p\u003e\u003cp\u003eVATS approach was adopted for every patient, and was converted to thoracotomy only in one case due to severe thoracic callous-like adhesions. The whole process of operation could be divided into three major steps.\u003c/p\u003e\u003cp\u003eDisassociation of adhesions: severe thoracic adhesion is inevitable because of previous VATS procedure or pleurodesis. Complete disassociation of thoracic adhesions is accomplished for every patient. If lung re-expansion is still evaluated to be less satisfying to fill whole thoracic cavity, then incision of pulmonary ligament and disassociation of hilar pleura is also performed to increase lung mobility.\u003c/p\u003e\u003cp\u003eResection of bullae: if bullae is detected during operation, resection with stapler is performed without covering.\u003c/p\u003e\u003cp\u003eMultiple drainage: this is a special technique developed by our team to ensure rapid and full lung re-expansion. we design to put 4–5 draining tubes into respective corners of cone-shaped thoracic cavity, usually including thorax apex, anterolateral highest point, posterior costophrenic sinus, cardio-phrenic angle region, and sometimes posterolateral highest point(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePostoperative chemical pleurodesis: Complete postoperative lung re-expansion confirmed by thoracic CT scan and no air leak are two essential prerequisites for performing repeated pleurodesis via chest tubes. The agent we used for chemical pleurodesis is 50% glucose mingled with iodophor.\u003c/p\u003e\u003cp\u003eAll patients recovered well and were discharged. Then they received periodic check, and were followed up till now.\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eThe data are presented as mean or mean ± SD. In order to\u003c/p\u003e\u003cp\u003eidentify possible hazard factor for pneumothorax recurrence post the second VATS, we made Logistic regression analysis taking several factors into account, including age, gender, resection of bulla or not, existence of persistent air leak post the second VATS. Statistical analysis is performed using SPSS Version 25 software (SPSS, Chicago, IL, USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe average age of 16 qualified patients is 31.7\u0026thinsp;\u0026plusmn;\u0026thinsp;15.3 years old. None of them complain history of smoking and occupational dust exposure.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDetailed clinical information of patients\u0026rsquo; previous VATS therapy or pleurodesis,and previous pneumothorax history are summarized in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Among them,15 cases had history of previous VATS,1 case had previous repeated drainage and chemical pleurodesis by erythromycin. 3 cases had history of previous contralateral pneumothorax which were cured respectively by drainage or VATS.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eClinical information for patients\u0026rsquo; pneumothorax recurrence post their previous VATS or chemical pleurodesis are summarized in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, including recurrence frequency ,medical treatment, etc. Among them,3 cases received chemical pleurodesis after recurrence post the first VATS, 2 cases by erythromycin, and 1 case by thrombin.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePerioperative information for patients\u0026rsquo; second VATS procedure are summarized in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, including operation duration time, blood loss, etc. All patients had severe thoracic adhesions, and most adhesions were in improper position which is named by us as ectopic adhesion(detailed explanation is mentioned below).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eClinical information of follow-up and recurrence treatment post the second VATS therapy are summarized in Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Among all patients,3 cases of recurrence happened.2 cases were cured by drainage ,1 case were by observation(oxygen inhalation).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical information of patients\u0026rsquo; first VATS therapy or pleurodesis and previous pneumothorax history\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eClinical information Frequency / Case\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePneumothorax frequency\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eMedical treatment\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObservation\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ethoracentesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003edrain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBulla resection\u003csup\u003e∮\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePleurodesis\u003csup\u003e★\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003echemical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emechnical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e* average pneumothorax frequency before the first VATS therapy.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u0026amp; observation means oxygen inhalation.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e# information of medical treatment for pneumothorax before the first VATS(case-time).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e∮information of the first VATS.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e★Pleurodesis during the first VATS or by drainage.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical information of pneumothorax recurrence post patients\u0026rsquo; first VATS therapy or pleurodesis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eClinical information\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCase/time\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eFrequency\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eMedical treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eobservation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ethoracentesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003edrain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eChemical pleurodesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e#average recurrence frequency.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePerioperative information for patients\u0026rsquo; second VATS therapy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePerioperative information\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eData\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eTime(minute)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e203.7\u0026thinsp;\u0026plusmn;\u0026thinsp;76.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eBlood loss(ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78\u0026thinsp;\u0026plusmn;\u0026thinsp;10.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDraining tubes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBulla resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDraining tube adjustment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePersistent air leak*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVacuum suction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eChemical pleurodesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 times\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 times\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e*postoperative air leak lasting more than 5 days is defined as persistent air leak\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFollow-up information and recurrence treatment post the second VATS therapy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eFollow up information\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eData\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecurrence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eobservation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDrain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime (month)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e*means follow up time.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSP is a relatively common disease of clinic significance. According to whether or not patients have underlying lung disease, SP is divided into primary spontaneous pneumothorax (PSP) and secondary spontaneous pneumothorax (SSP)\u003csup\u003e(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/sup\u003e. Till now, worldwide epidemiology study of SP is lacking. Several large-scale studies could be retrived which are based on data from French national dataset\u003csup\u003e(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/sup\u003e, Korea National Sample Cohort (NSC)\u003csup\u003e(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/sup\u003e, England General Practice Research Database (GPRD)\u003csup\u003e(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/sup\u003e.The authors report an annual rate of SP of 19.2\u0026ndash;66 per 100 000 population, with a male-to-female ratio of approximately 3.3\u0026ndash;10:1. More specifically, prevalence rate of PSP is estimated to account for 14\u0026ndash;50% of SP annual prevalence rate. Clinically recurrence rate of SP is as high as 17\u0026ndash;49%\u003csup\u003e(19\u0026ndash;21)\u003c/sup\u003e. Therefore, operation is recommended for recurrent SP or the first episode of SP with persistent air leak lasting more than 5\u0026ndash;7 days. Since the pathogenesis of SP generally arises from rupture of bleb/bulla or emphysema-like lung tissue, the whole procedure usually includes 2 major steps, namely resection of bullas and mechanical/chemical pleurodesis. However, the vexed problem of relapse is not completely resolved yet.\u003c/p\u003e \u003cp\u003eAs mentioned above, recurrent pneumothorax post previous VATS or pleurodesis is refractory and challenging to decide further therapy since presently it is difficult to totally prevent recurrence. The reason for postoperative pneumothorax recurrence is uncertain. Maria et al made large-scale retrospective study on patients of PSP who received treatment by VATS procedure, aiming to identify risk factors for postoperative pneumothorax recurrence. They analyzed different methods of pleurodesis and other clinical factors, and concluded that only prolonged postoperative air leak was independent risk factor for pneumothorax recurrence post VATS treatment, while different methods of pleurodesis did not have significant impact on recurrence\u003csup\u003e(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/sup\u003e. Andrea et al made similar study with consistent conclusion, moreover, they also identified female-gender was another independent risk factor for pneumothorax recurrence post VATS treatment\u003csup\u003e༈23༉\u003c/sup\u003e. During recent years, we accumulate some experiences in treating such refractory SP, then propose that unsatisfying lung re-expansion at early stage postoperatively is an important reason for later recurrence. In a way our viewpoint is consistent with previous studies.To illustrate, we introduce an important concept of ectopic adhesion which has not been proposed before, namely some part of lung parenchyma does not attach to its usually attached parietal pleura when in natural state of full expansion due to insufficient lung re-expansion at early stage postoperatively commonly seen in clinical practice. Then under effect of pro-adhesion factors, such as chemical irritation or mechanical abrasion, so that improper thoracic adhesion is easy to form. Obviously such ectopic adhesion would impede lung natural expansion to fill thoracic cavity, so that over-expansion of other part of lung parenchyma is needed as one of compensatory measures to fill residual thoracic cavity(Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA-C). Theoretically ectopic adhesion would exert extra negative pressure on lung parenchyma to neutralize traction by over expansion, thus new pulmonary emphysema and bullae/bleb could gradually form under effect of such persistent negative pressure. This situation is similar to that in lung apex where usually the highest negative pressure exists and bullae/bleb is easy and the most often to form. Our proposed theory might explain why pneumothorax recur post wedge resection and pleurodesis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eBased on our proposed theory, we gradually establish surgical strategy and special technique in refractory pneumothorax therapy with satisfying clinical effect. Firstly, postoperative recurrent pneumothorax usually exhibit irregular air cavities in thoracic CT scan image due to severe adhesions caused by previous treatment. According to our experience, thoracic adhesions in most cases are ectopic adhesion. Therefore, fully disassociation of thoracic adhesion is indispensable and the most difficult step of re-operation for refractory pneumothorax. If tight adhesion between lung and major vessel is detected(Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD), disassociation by VATS would be dangerous and challenging for surgeon. Considering principle of safety priority, proper expansion of incision is sometimes advisable. Besides, formation of fibrous layer covering lung parenchyma is also common due to previous pleurodesis. Theoretically fibrous layer could be a hampering factor for lung full expansion. If possible, stripping of fibrous layer is recommended. Nevertheless, it is unwise to strip fibrous layer tightly attached to lung parenchyma, otherwise excessive lung injury would be disastrous for lung expansion. According to our experience, fibrous layer might delay lung expansion. However, it is certain that lung parenchyma limited by fibrous layer is still able to gradually expand to fill residual thoracic cavity in existence of sufficient drainage. Sometimes hilar pleura is also disassociated to release more lung mobility so as to ensure lung postoperative expansion sufficient to fill thoracic cavity.\u003c/p\u003e \u003cp\u003eSecondly, multi-tube drainage is a special surgical technique developed by us to ensure lung re-expansion at early stage postoperatively and avoid ectopic adhesion. The Rationale is utilizing chest tube drainage as pulling force so as to ensure lung natural and full expansion (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA). Since lung re-expansion could hardly be satisfying at early stage postoperatively because of insufficient breath depth due to pain. Moreover, since lung volume is often reduced due to previous wedge resection, it could be another unfavorable factor for lung expansion to fill thoracic cavity. Considering it is quite prone to form new adhesions in thoracic cavity after disassociating severe adhesions, rapid re-expansion is crucial for avoidance of new ectopic adhesions. Therefore, we design to put several draining tubes into corners of thoracic cavity, thereby pulling lung to expand outwards, similar to pulling four corners of a sail to keep it outspread(Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB). According to our experience, these draining tubes are particularly useful to lead lung to re-expand naturally. To our knowledge, this technique has not been reported before.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThirdly, final step is to perform repeated chemical pleurodesis via chest tubes. We emphasize that complete lung re-expansion confirmed by postoperative thoracic CT scan and no air leak are two essential prerequisites for performing pleurodesis. The agent we used for pleurodesis is usually 50% glucose mingled with iodophor. The purpose of pleurodesis is to generate diffuse thoracic adhesions so as to seal thoracic cavity which could effectively avoid recurrence in spite of formation of new bullae/bleb detected by others in such recurrent pneumothorax\u003csup\u003e(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eBy these measures, all patients included in this study achieved satisfying clinical effect. In future, large scale prospective study is needed to further evaluate efficacy of these measures in reducing refractory pneumothorax recurrence.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eInsufficient lung expansion post operation due to improper ectopic adhesions may play important role in pneumothorax recurrence. Our special technique utilizing outwards drainage to achieve satisfying lung re-expansion at early stage postoperatively based on fully disassociation of thoracic adhesions could effectively avoid ectopic adhesions, which is crucial for prevention of refractory pneumothorax postoperative recurrence.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cem\u003eSP for\u0026nbsp;\u003c/em\u003eSpontaneous pneumothorax;\u003c/p\u003e\n\u003cp\u003ePSP for primary spontaneous pneumothorax;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSSP for secondary spontaneous pneumothorax;\u003c/p\u003e\n\u003cp\u003eVATS for video-assisted thoracic surgery;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThis is a retrospective study, informed consent to participate\u0026nbsp;were obtained from all patients, and patients\u0026rsquo; information are fully protected. Ethics approval and consent\u0026nbsp;is formally waived by Ethics Committee of Beijing University of Chinese Medicine Dongfang Hospital according to latest Chinese national biologic research ethical guideline .\u003c/p\u003e\n\u003cp\u003eConsent for publication: not applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eData sharing is not applicable to this article as no datasets were generated or analysed during the current study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding:No\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions:\u003c/p\u003e\n\u003cp\u003eHailong Liang is in charge of data procession, draft writing and submission; Tiansheng Yan is in charge of study design, manuscript review;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eZhao fei Yan is in charge of data collection.\u003c/p\u003e\n\u003cp\u003eXuanchen Liu is in charge of data collection.\u003c/p\u003e\n\u003cp\u003eAcknowledgements: not applicable.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; information\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eProfessor Tiansheng Yan is a famous thoracic surgeon in China with great reputation in field of complex spontaneous pneumothorax surgical therapy.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ede Hoyos A, Fry WA. Chapter 58: Pneumothorax. In: Shields TW, LoCicero J, Reed CE, Feins RH, eds. General Thoracic Surgery. 7th ed. Philadelphia: Lippincott Williams \u0026amp; Wilkins; 2009:739-62.\u003c/li\u003e\n\u003cli\u003eLesur O., Delorme N., Fromaget J. M., Bernadac P. ,Polu J. M. Computed tomography in the etiologic assessment of idiopathic spontaneous pneumothorax. Chest, 1990,98:341\u0026ndash;347.\u003c/li\u003e\n\u003cli\u003eBaumann MH, Strange C, Heffner JE, Light R, Kirby TJ, Klein J, et al. Management of spontaneous pneumothorax: An American College of Chest Physicians Delphi consensus statement. Chest 2001;119:590-602. \u003c/li\u003e\n\u003cli\u003eMacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax 2010;65:ii18-ii31. \u003c/li\u003e\n\u003cli\u003eCardillo G, Facciolo F, Giunti R, Gasparri R, Lopergolo M, Orsetti R, et al. Videothoracoscopic Treatment of Primary Spontaneous Pneumothorax: a 6-Year Experience. Ann Thorac Surg,2000; 69:357-61.\u003c/li\u003e\n\u003cli\u003eTschopp JM, Bintcliffe O, Astoul P, Canalis E, Driesen P, Janssen J, et al. ERS task force statement: diagnosis and treatment of primary spontaneous pneumothorax. Eur Respir J ,2015;46:321\u0026ndash;35.\u003c/li\u003e\n\u003cli\u003eShaikhrezai K, Thompson AI, Parkin C, Steven Stamenkovic S, William S WalkerW.S.. Video-assisted thoracoscopic surgery management of spontaneous pneumothorax--long-term results. Eur J Cardiothorac Surg ,2011;40:120\u0026ndash;3. \u003c/li\u003e\n\u003cli\u003e Campos J. R. de.,Vargas FS, Campos Werebe E.de.,\u003csup\u003e \u003c/sup\u003e Cardoso P, Teixeira L.R., Jatene F.B., et al. Thoracoscopy talc poudrage: a 15-year experience. Chest, 2001;119:801\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eLee H.W., Lee J.I., Kim K.W., Park K.Y.，Park C.H.. The effects of additional tetracycline pleurodesis during thoracoscopic procedures for treating primary spontaneous pneumothorax. Korean J Thorac Cardiovasc Surg 2008;41:729\u0026ndash;35.\u003c/li\u003e\n\u003cli\u003eCattoni M, Rotolo N, Mastromarino MG, Cardillo G, Nosotti M, Mendogni P, et al. Analysis of pneumothorax recurrence risk factors in 843 patients who underwent videothoracoscopy for primary spontaneous pneumothorax: results of a multicentric study. Interact CardioVasc Thorac Surg 2020;31:78\u0026ndash;84. \u003c/li\u003e\n\u003cli\u003eMao Y., Zhang Z., Zeng W., Zhang W., Zhang J., You G., et al. A clinical study of efficacy of polyglycolic acid patch in surgery for pneumothorax:a systematic review and meta-analysis. J. Cardiothorac. Surg. 2020;15:117. doi: 10.1186/s13019-020-01137-8.\u003c/li\u003e\n\u003cli\u003eSim S.K.R., Nah S.A., Loh A.H.P., Ong L.Y., Chen Y. Mechanical versus Chemical Pleurodesis after Bullectomy for Primary Spontaneous Pneumothorax: A Systemic Review and Meta-Analysis. Eur. J. Pediatr. Surg. 2020;30:490\u0026ndash;496. doi: 10.1055/s-0039-1697959. \u003c/li\u003e\n\u003cli\u003eCho S, Jheon S, Kim DK, Kim HR, Huh DM, Lee S ,et al. Results of repeated video-assisted thoracic surgery for recurrent pneumothorax after primary spontaneous pneumothorax. Eur J Cardiothorac Surg 2018;53:857\u0026ndash;61.\u003c/li\u003e\n\u003cli\u003eCardillo G, Facciolo F, Regal M, Carbone L, Corzani F, Ricci A ,et al. Recurrences following video thoracoscopic treatment of primary spontaneous pneumothorax: the role of redo-video thoracoscopy. Eur J Cardiothorac Surg 2001;19:396\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eSahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med 2000,342:868\u0026ndash;74.\u003c/li\u003e\n\u003cli\u003eBobbio A, Dechartres A, Bouam S, et al.Epidemiology of spontaneous pneumothorax:gender-related differences. Thorax 2015;70:653\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eKim D, Jung B, Jang B-H, et al. Epidemiology and medical service use for spontaneous pneumothorax: a 12-year study using nationwide cohort data in Korea. BMJ Open 2019,9(10):e028624. \u003c/li\u003e\n\u003cli\u003eDheeraj Gupta, Anna Hansell, Tom Nichols, Trinh Duong, Jon G Ayres, David Strachan. Epidemiology of pneumothorax in England.Thorax,2000(55):666\u0026ndash;671.\u003c/li\u003e\n\u003cli\u003eChen, J. S. et al. Simple aspiration and drainage and intrapleural minocycline pleurodesis versus simple aspiration and drainage for the initial treatment of primary spontaneous pneumothorax: An open-label, parallel-group, prospective, randomised, controlled trial. Lancet,2013, 381:1277\u0026ndash;1282. \u003c/li\u003e\n\u003cli\u003eMassongo M, Leroy S, Scherpereel A, et al.Outpatient management of primary spontaneous pneumothorax: a prospective study. Eur Respir J.2014,43:582\u0026ndash;90.\u003c/li\u003e\n\u003cli\u003eB.V. Udelsman, D.C. Chang, M. Lanuti et al., Risk factors for recurrent spontaneous pneumothorax: A population level analysis, The American Journal of Surgery.2021 10;S0002-9610(21)00323-8.\u003c/li\u003e\n\u003cli\u003eCattoni M, Rotolo N, Mastromarino MG, Cardillo G, Nosotti M, Mendogni P, et al. Analysis of pneumothorax recurrence risk factors in 843 patients who underwent videothoracoscopy for primary spontaneous pneumothorax: results of a multicentric study. Interact CardioVasc Thorac Surg 2020;31:78\u0026ndash;84.\u003c/li\u003e\n\u003cli\u003eImperatori A, Rotolo N, Spagnoletti M, Festi L, Berizzi F, Di Natale D ,et al. Risk factors for postoperative recurrence of spontaneous pneumothorax treated by video-assisted thoracoscopic surgery. Interact CardioVasc Thorac Surg 2015;20:647\u0026ndash;53.\u003c/li\u003e\n\u003cli\u003eCho S, Jheon S, Kim DK, Kim HR, Huh DM, Lee S, et al. Results of repeated video-assisted thoracic surgery for recurrent pneumothorax after primary spontaneous pneumothorax. Eur J Cardiothorac Surg 2018;53:857\u0026ndash;61.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"spontaneous pneumothorax, refractory pneumothorax, reoperation, recurrence","lastPublishedDoi":"10.21203/rs.3.rs-5363903/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5363903/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eRecurrence is major existing problem in spontaneous pneumothorax (SP) therapy. Refractory SP refers to recurrent SP post previous VATS or pleurodesis. There is no consensus on how to treat refractory SP so as to avoid another recurrence. We introduce our experiences in reoperation for such refractory SP.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e we retrospectively review 16 consecutive cases of refractory SP who received repeated VATS treatment in Beijing University of Chinese medicine Dongfang Hospital. Perioperative data are documented, and postoperative follow up is made, with emphasis on introducing surgical strategy and special technique established by our team, and discussing how these measures could effectively avoid recurrence.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong all qualified patients,15 cases had previous VATS history,1 case had previous chemical pleurodesis history. VATS therapy was performed in all cases, and was converted to thoracotomy only in 1 case due to severe thoracic callous-like adhesions. All patients recovered well and were discharged. Mean postoperative follow-up time is 15.2 months. 3 cases of recurrence happened. Among them,2 cases were cured by drainage ,1 case were cured with oxygen inhalation.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eOur proposed surgical strategy and techniques may effectively treating refractory SP and prevent further recurrence.\u003c/p\u003e","manuscriptTitle":"Surgical treatment for refractory spontaneous pneumothorax （experience of 16 cases）","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-03 23:51:15","doi":"10.21203/rs.3.rs-5363903/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b9e0b41c-212b-4d3c-b078-e0289945fc22","owner":[],"postedDate":"December 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-01-28T08:39:09+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-03 23:51:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5363903","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5363903","identity":"rs-5363903","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}