dokonano analizy dokumentacji medycznej pacjentw z samoistn odm opucnow leczonych w klinice chirurgii dziecicej uniwersytetu medycznego w biaymstoku .
w latach 20042014 hospitalizowano 22 dzieci z powodu samoistnej odmy opucnowej  18 chopcw i 4 dziewczynki , w wieku od 14 do 17 lat ( rednio 16,6 miesica ) .
w 11 przypadkach ( 52% ) w leczeniu jednostronnej odmy opucnowej zastosowano jednorazowy drena jamy opucnowej , z dobrym skutkiem .
w pozostaych 11 przypadkach wystpi nawrt odmy , w czasie od 3 tygodni do 2 lat .
u pacjentw z odm nawrotow wykonano drena jamy opucnowej oraz tomografi komputerow ( tk ) klatki piersiowej .
szeciu pacjentw z tej grupy , na podstawie obrazu tk , w ktrym stwierdzono obecno pcherzy rozedmowych , zakwalifikowano do torakoskopii ( video - assisted thoracoscopic surgery  vats ) .
w trakcie vats wykonano zamknicie przetok oskrzelowo - opucnowych w obrbie pknitych pcherzy rozedmowych za pomoc ptli endoloop .
u chopca , u ktrego nie stwierdzono efektu terapeutycznego po vats , wykonano minitorakotomi z dostpu pod pach  za pomoc staplera usunito szczyt puca oraz wykonano pleurodez , z dobrym skutkiem .
poznanie czynnikw ryzyka powstania nawrotowej samoistnej odmy opucnowej pozwala na kwalifikowanie chorych do odpowiednich , maoinwazyjnych procedur leczniczych  vats .
w przypadku niepowodzenia vats , minitorakotomia pachowa zapewnia powodzenie leczenia , zaoszczdzajc choremu blu pooperacyjnego i zapewniajc dobry efekt kosmetyczny .
a primary spontaneous pneumothorax ( psp ) is defined as a spontaneously occurring pneumothorax in a person without clinically apparent underlying lung disease or trauma .
the psp occurs at a frequency of 7.4 - 18 cases per 100,000 population per year in men and 1.2 - 6 cases per 100,000 population per year in women .
the psp typically occurs in young adults ( peak age incidence 20 - 30 years ) and is uncommon in the paediatric population [ 2 , 3 ] .
therefore the research on psp has focused on management strategies in adults , and paediatric population data are lacking .
the management of psp varies and depends on the experience and the speciality of the physician - in - charge .
the aim of this study was to review paediatric spontaneous pneumothorax and describe diagnostic and therapeutic approaches and to review our institutional experience with spontaneous pneumothorax .
the patients in this study consisted of 22 consecutive paediatric patients with confirmed psp , who were treated from 2004 to 2014 at the paediatric surgery clinic and were identified from an administrative database .
we excluded patients with secondary pneumothorax due to external or surgical trauma , underlying lung disease ( asthma , malignancy , infection , connective tissue disease , or congenital lung disease ) .
demographic and clinical data were collected , including preoperative factors ( age , height , weight ) , duration of hospital stay from the time of presentation to the ed to discharge , length / duration / type of preoperative management , type of procedure , recurrence of pneumothorax , failure rate of the procedure , length of postoperative air leak , narcotic requirement , and complications .
the patients were predominantly male  there were 18 boys and 4 girls ( boys to girls ratio 4 : 1 ) .
the mean age of the patients was 16 years , 6 months  month ( range 14 - 17 ) .
the mean body mass index was 20.1 ( ranging from 17 to 24 ) . in all patients , the diagnosis of psp
was confirmed by chest radiographs . in 11 patients ( 52% ) , chest tubes inserted on diagnosis of the pneumothorax
were removed 48 hours after placement and resulted in resolution of the pneumothorax without need for additional intervention .
one patient with persistent air leak after chest tube placement for more than seven days have had computed tomography ( ct ) of the chest , and after confirming of the existence of apical blebs was treated with video - assisted thoracoscopic surgery ( vats ) procedure with success .
another 10 patients were hospitalised because of recurrence of psp , from three weeks to two years after the first episode of psp ( mean 5 months  1 month ) .
all of those patients were treated with thoracostomy and had ct of the chest performed . in five patients , ct of the chest revealed the apical blebs , and those patients
prolonged postoperative air leak ( over seven days ) was observed in three patients ( 50% ) ; those patients required reoperation during the same hospitalisation .
one of those patients had resection of the apex of the lung with endo - gia stapler .
another patient with recurrent psp , after two vats procedures that failed to visualise apical blebs , was treated with success using an open mini axillary thoracotomy and resection of apical blebs with endo - gia stapler .
the tube was placed over a needle after instilling local anaesthetic in the fifth intercostal space at the midaxillary line .
chest tubes were secured to the skin with suture , and a sterile dressing was applied after attaching the chest tube to a underwater seal collection system set at 10 cm h2o suction .
a chest x - ray was repeated 4 - 6 hours after removal to evaluate for recurrent pneumothorax .
three of the patients with pneumothorax required longer than 48 hours before chest tube removal but did not require additional intervention .
another two patients were operated on because of persistent air leak after chest tube placement for over seven days . before the surgical intervention , a chest ct was routinely performed for patients with recurrent psp to localise the bullae and blebs , which identified apical blebs in 6 out of 11 patients ( 54.5% )
. indications for operation  video - assisted thoracoscopic surgery ( vats )  were : persistent air leak after chest tube placement for more than seven days in one patient , recurrent ipsilateral pneumothorax in four patients , and occurrence of a contralateral pneumothorax in one patient with apical blebs confirmed in ct of the chest .
valved trocars were used to allow co2 insufflation to assist with lung compression and to allow visualisation of the entire visceral pleura .
video - assisted thoracoscopic surgery procedures were performed under a 5-mm thoracoscopic view using a standard three - port approach .
a 5-mm trocar was introduced through an intercostal space in the midaxillary line for insertion of a 30 telescope .
if the patient already had a chest tube , this was removed and the chest tube tract was used for insertion of a second 5-mm trocar for insertion of operating instruments .
a third trocar was inserted in the anterior axillary line , 5 mm or 12 mm trocar , for insertion of an endoloop or an endo - gia stapler if blebectomy was to be performed . in the absence of evident bullae ,
250 ml of saline solution was instilled into the pleural cavity and the lung was ventilated to identify the air leak . at the time of the initial vats procedure , apical blebs were identified in four out of five patients .
if blebs were visualised , bleb resection was performed using endoloops or an endoscopic stapling device ( figs .
the lung was inspected for bleeding and , after pulmonary reinsufflation , checked for air leaks .
pleural adhesions after pleural abrasion visible during the second video - assisted thoracoscopic surgery ( vats ) in a 17-yearold patient apical bleb in a 16-year - old patient resection of apical bleb using an endoloop in a 16-year - old patient line of endo - gia stapler resection of an apex of left lung because of apical blebs in a 17-year - old patient mechanical pleurodesis was achieved using a cautery scratch . at the end of the procedure ,
the chest tubes were typically removed when the air leak ceased and postoperative chest radiographs showed no residual pneumothorax . on average , postoperative pain medications , which included perfalgan , dolargan , or morphine , were given intravenously or intramuscularly for 1 - 2 days , after which the patients were given oral analgesics .
the mean interval between the initial hospitalisation and recurrence was 5 months  1 month ( range from 3 weeks to 2 years ) .
recurrent pneumothorax was evacuated by closed thoracostomy with success in four patients ( 40% ) .
after a second vats procedure in three patients , we did not observe recurrent psp in two of these patients .
one patient with recurrent psp , after two vats procedures failed to visualise apical blebs , was treated successfully with an open mini axillary thoracotomy and resection of apical blebs with endo - gia stapler ( fig . 1 and 4 ) .
the mean follow - up period was 4 years 3 months  1 month ( range 6 months  10 years ) .
there were no postoperative deaths , and none of the patients required monitoring in the intensive care unit .
data are presented as the mean  standard deviation or frequencies and percentages , as appropriate .
comparisons were made using mann - whitney u test and  , as appropriate , and statistical significance was considered when p < 0.05 .
patients with primary spontaneous pneumothorax are generally young and healthy . most cases of primary spontaneous pneumothorax ( psp ) occur in healthy adolescents and in young adults in the absence of prior lung disease .
the psp is a relatively rare disease entity in children . according to margolis et al . , who performed a retrospective study of 156 patients with psp , the median age of presentation was 19 years , and 69% of patients were male .
the goal in the management of psp is to re - expand the lung and prevent recurrence with minimal morbidity .
rupture of blebs and bullae may be responsible for the occurrence of most cases of psp .
the formation of bullae is most likely to be multifactorial , including physical characteristics , smoking , anatomic abnormalities of the bronchial tree , sex differences , genetic factors , and growth [ 5 , 7 ] . among our patients
there were no smokers , but they generally had asthenic features , and the mean body mass index ( bmi ) was 20.1 .
previous studies have suggested that growth during adolescence causes a rapid increase in the vertical dimension of the thorax compared to the horizontal dimension .
this rapid increase causes an increase in negative pressure at the apex of the lung , which may lead to formation of bullae and may cause psp upon rupturing [ 5 , 7 ] .
the most recent guidelines from the american college of chest physicians consensus statement ( 2001 ) recommend that patients with small pneumothorax should be observed in the emergency department for 3 - 6 hours and discharged home if repeat chest radiograph shows no progression of pneumothorax [ 8 , 9 ] . the average rate of recurrent pneumothorax after the first episode of psp with conservative treatment
was reported at 30% , and it seems to be higher in children , ranging from 50 to 60% [ 5 , 1012 ] .
the british thoracic society recommends needle aspiration as the initial treatment of choice , but the american college of chest physicians consensus prefers insertion of small - bore catheters (  14 fr ) or chest tubes ( 16 - 22 fr ) . needle aspiration is safe and less painful and leads to a shorter hospital stay than chest tube insertion . however , needle aspiration is only successful in approximately 60% of patients , and more than half of these patients needed to be hospitalised .
chan and lam in their study found an even lower success rate after simple needle aspiration of psp ( 50.5% ) , but only 15% success rate if the pneumothorax was larger than 40% . nonetheless , pain scores were greater in the tube thoracostomy group . in our department
we initially treat patients with psp with chest tube insertion , and in many cases only continuous suction allows complete evacuation of air from the pleural space and full expansion of the lung .
some authors suggest that life - threatening haemothorax might be related to the use of the anterior approach .
there are reports of pulmonary artery injury and cardiac tamponade after decompression of the pneumothorax performed in the second intercostal space , midclavicular line [ 8 , 16 ] .
bearing in mind those complications we use the fifth intercostal space in the anterior or mid - axillary line for chest tube drainage , and we have not observed thoracostomy complications in our series of patients . pulmonary fibrosis , a history of smoking , asthenic habitus , and younger age
have been reported to be independent risk factors for recurrences after the first episode of psp [ 5 , 17 ] .
recurrence rates after a first episode of psp treated with chest drainage vary from 16 to 52% .
after a first recurrence , the likelihood of subsequent recurrences seems to increase progressively up to 62% for a second and 83% for a third recurrence , which is why an operative intervention is indicated in such cases [ 1 , 18 ] .
some authors   advocate surgery also for patients with air - leak persisting beyond 14 days . in our department , patients with psp are qualified for surgical treatment when air - leak persists beyond seven days . prior to that
, we perform ct of the chest to identify blebs  these patients will benefit from surgical intervention and resection of bullae . also , the american college of chest physicians ( accp ) state that patients should be operated on at the second recurrence , except for those at risk  scuba divers , pilots etc . , or those presenting with persistent air leak . in the recent years vats
video - assisted thoracoscopic surgery was first reported in 1989 for treatment of secondary spontaneous pneumothorax in children with cystic fibrosis .
video - assisted thoracoscopic surgery is safe and effective , with low morbidity and minimal invasiveness , and has been performed with good results in children with psp [ 5 , 7 , 11 ] .
the recurrence rate of psp in the group of children after vats has been reported as 4.9 - 11.8% [ 5 , 7 , 11 ] .
these recurrence rates are higher than those of adults 1.7 - 8.3% [ 22 , 23 ]
. the higher risk of recurrence in children is not related to surgical failure , but it is often associated with the formation of new bullae . it has been reported that in children who develop recurrent psp , half will have recurrence on the contralateral side . the use of ct scanning is advocated to identify contralateral blebs or bullae [ 20 , 24 ] .
we also observed a significant decrease in recurrences with increasing experience , which is consistent with the observations of other authors .
the thoracoscopic approach is a relatively new technique , and there is an impact of the learning curve .
the aetiology of postoperative recurrence includes undiscovered bullae , inadequate resection margins that fail to include healthy lung tissue , coexisting severe emphysema , and newly grown bullae [ 5 , 26 ] .
several authors have recently reported their experiences with fibrin glue reinforcement of staple lines during thoracoscopic treatment of pulmonary bleb disease in adults [ 27 , 28 ] . comparing the results of chest tube drainage and vats for recurrent psp , patients undergoing vats or limited thoracotomy for psp have recurrence rates of 13% and 0% , respectively ,
after surgical intervention with the resection of blebs with the lung tissue , we advocate our patients to avoid activities that put additional strain on the lungs , including scuba diving , strenuous exercise , and playing wind musical instruments .
a strong and adequate pleural adhesion is indicated to prevent recurrence of the pneumothorax . regarding the optimal method for pleurodesis
reports in adult patients have advocated blebectomy plus mechanical pleurodesis or chemical pleurodesis [ 22 , 23 ] .
pleurectomy has a very low incidence of recurrence , ranging from 0 to 1% , by open thoracotomy , transaxillary minithoracotomy , or vats .
unfortunately , pleurectomy may lead to increased morbidity , related to postoperative haemorrhage complications [ 30 , 31 ] .
also , pleurectomy may make secondary thoracotomy extremely difficult , and performance of an apical pleurectomy alone will not prevent recurrence in the lower part of the chest .
talc poudrage is rarely performed , even though available data show that both vats bullectomy plus pleurodesis and medical talc poudrage without bullae treatment are equally effective .
talc poudrage has two main drawbacks : the risk of postoperative pleural infection ; and the creation of tight adhesions that are difficult to free , so another surgical intervention becomes necessary in the future . in view of those facts ,
pleural abrasion is widely accepted as a reasonable compromise and is successfully performed in our department .
the  last resort treatment for children who have failed vats is an open thoracotomy with direct surgical treatment of the subpleural bleb or cyst .
several studies comparing vats to open surgery have documented lower recurrence rates after thoracotomy than after vats [ 3234 ] .
open thoracotomy is more effective in preventing recurrence but greatly increases discomfort and morbidity . in view of diminishing morbidity ,
better cosmetic result , and shortening of the hospital stay , in our department we prefer an axillary mini - thoracotomy approach , even though the view offered by an axillary mini - thoracotomy is so limited that it makes it almost impossible to examine the lower lobe . in our series we had to perform thoracotomy only in one patient .
although our study is limited by the small number of patients , we conclude that most patients resolve their spontaneous pneumothorax and air leak with tube thoracostomy alone . for those patients in whom
chest tube drainage is not effective , and for those with recurrent psp , early vats and bullectomy combined with pleural abrasion is the most efficient intervention , obviating long periods of ineffective chest tube drainage .
 introductionprimary spontaneous pneumothorax ( psp ) occurs at a frequency of 7.4 - 18 cases per 100 000 population per year . 
 the psp typically occurs in young adults and is uncommon in children . 
 the aim of this study was to review our institutional experience with psp in children.material and methodstwenty - two paediatric patients with confirmed psp , treated from 2004 to 2014 at the paediatric surgery clinic . 
 there were 18 boys and 4 girls . 
 the mean age was 16 years , 6 months  1 month ( range 14 - 17 ) . 
 the mean body mass index ( bmi ) was 20.1 ( ranging from 17 to 24).resultsthe recurrence rate of psp was 48% . 
 the mean interval of the recurrence was 5 months  1 month ( range from 3 weeks to 2 years ) . 
 recurrent pneumothorax was evacuated by thoracostomy with success in four patients . 
 the first video - assisted thoracoscopic surgery ( vats ) procedure had a failure rate of 50% . 
 after second vats procedure , we did not observe recurrent psp in two patients . 
 one patient with recurrent psp , after two vats procedures , was treated with success , with an open mini axillary thoracotomy . 
 the mean follow - up period was 4 years 3 months  1 month ( range 6 months  10 years ) . 
 we have not noted any intraoperative complications.conclusionsalthough our study is limited by the small number of patients , we conclude that most patients resolve their spontaneous pneumothorax and air leak with tube thoracostomy alone . for those patients in whom 
 chest tube drainage is not effective , and for those with recurrent psp , early vats and bullectomy combined with pleural abrasion is the most efficient intervention . 
Wstp
Materia i metody
Wyniki
Wnioski
Introduction
Material and methods
Results
Statistics
Discussion
Conclusions
Disclosure