Delayed referral reduces the success of video-assisted thoracoscopic surgery for spontaneous pneumothorax

Background. Video-assisted thoracoscopic surgery (VATS) is now the generally preferred surgical treatment for spontaneous pneumothorax but is more difficult once pleural adhesions have developed. To test the hypothesis that VATS is under-used because of prolonged pleural intubation, we have audited the effect of preoperative management on subsequent surgical outcome. Method. Data are expressed as median (range). A prospective audit of clinical outcome in 42 consecutive patients (30 male, 12 female, aged 39 [19-81] years) referred to a Regional Unit for non-elective pneumothorax surgery. VATS was attempted whenever possible. Results. VATS was successful in 32 patients (group V) but 10 (24%) patients (group T) required thoracotomy and decortication of an empyema thoracis. Only seven (17%) patients were operated upon within 7 days of presentation, and 10 patients (24%) waited for more than 21 days. The delay from presentation to operation was significantly longer in group T (22 days vs. 10 days, P<0.05, Wilcoxon). There were significantly more preoperative pleural interventions in patients in group T than in group V (P<0.05, Wilcoxon). Postoperative stay was longer in group T (7 days vs. 3 days, P<0.05) and there was a significant overall correlation between preoperative delay and postoperative stay (r=0.64). Conclusion. Delayed referral for pneumothorax surgery and multiple pleural interventions predispose to pleural sepsis and preclude VATS detrimentally affecting clinical outcome. Changes in referral practice are advocated.