title: First Episode of Spontaneous Pneumothorax: CT-based Scoring to Select Patients for Early Surgery.
abstract: BACKGROUND
  Although recurrence of primary spontaneous pneumothorax (PSP) is frequent, guidelines do not routinely recommend surgery after first presentation. A CT-based lung dystrophy severity score (DSS) has recently been proposed to predict recurrence following conservative therapy. This study compares the DSS in surgically and conservatively treated patients.
  
  
  METHODS
  This is a retrospective analysis of first episode PSP patients, comparing video-assisted thoracic surgery (VATS; group A) to conservative treatment with or without chest drainage (group B). CT scans were reviewed for blebs or bullae, and patients were assigned DSS values and stratified into risk groups (low and high-grade). Primary end point was ipsilateral or contralateral recurrence.
  
  
  RESULTS
  Fifty-six patients were included, 33 received VATS and 23 conservative treatment. In total, 37.5 % experienced recurrence, with a 5-year estimated recurrence rate of 40.7 % (group A: 13.3 %; group B: 73.9 %; p < 0.001). In group B, detection of any dystrophic lesions resulted in significantly higher 5-year recurrence rates (86.7 vs. 50.0 %; p = 0.03), there was no significant difference in group A (17.7 vs. 7.7 %; p = 0.50). Greater DSS values correlated with higher 5-year recurrence rates in group B (p = 0.02), but not in group A (p = 0.90). Comparing low- and high-grade patients in group B resulted in a significant 5-year recurrence rate of 53.8 versus 100 % (p = 0.023).
  
  
  CONCLUSIONS
  The DSS is useful to indicate VATS after the first episode. For routine application, assigning patients to low- and high-grade groups seems most practical. We recommend CT-evaluation for every PSP patient and early surgery for those with lesions exceeding one bleb. After VATS, the preoperative DSS is not beneficial in predicting recurrence.
authors.affiliation: Department of Surgery, Paracelsus Medical University, Müllner-Hauptstrasse 48, 5020, Salzburg, Austria. f.primavesi@salk.at.
authors.forename: Florian
authors.initials: F
authors.lastname: Primavesi
authors.affiliation: Department of Surgery, Paracelsus Medical University, Müllner-Hauptstrasse 48, 5020, Salzburg, Austria.
authors.forename: Tarkan
authors.initials: T
authors.lastname: Jäger
authors.affiliation: Department of Radiology, Paracelsus Medical University, Müllner-Hauptstrasse 48, 5020, Salzburg, Austria.
authors.forename: Thomas
authors.initials: T
authors.lastname: Meissnitzer
authors.affiliation: Department of Surgery, Paracelsus Medical University, Müllner-Hauptstrasse 48, 5020, Salzburg, Austria.
authors.forename: Selina
authors.initials: S
authors.lastname: Buchner
authors.affiliation: Department of Surgery, Paracelsus Medical University, Müllner-Hauptstrasse 48, 5020, Salzburg, Austria.
authors.forename: Silvia
authors.initials: S
authors.lastname: Reich-Weinberger
authors.affiliation: Department of Surgery, Paracelsus Medical University, Müllner-Hauptstrasse 48, 5020, Salzburg, Austria.|Department of Visceral-, Transplant- and Thoracic Surgery, Center of Operative Medicine, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria.
authors.forename: Dietmar
authors.initials: D
authors.lastname: Öfner
authors.affiliation: Department of Surgery, Paracelsus Medical University, Müllner-Hauptstrasse 48, 5020, Salzburg, Austria.
authors.forename: Jörg
authors.initials: J
authors.lastname: Hutter
authors.affiliation: Department of Surgery, Paracelsus Medical University, Müllner-Hauptstrasse 48, 5020, Salzburg, Austria.
authors.forename: Manuela
authors.initials: M
authors.lastname: Aspalter
mesh_terms: D000328:Adult; D000368:Aged; D000066491:Clinical Decision-Making; D000072700:Conservative Treatment; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D061330:Multidetector Computed Tomography; D018579:Patient Selection; D011030:Pneumothorax / Q000000981:diagnostic imaging* / Q000628:therapy*; D012008:Recurrence; D012189:Retrospective Studies; D012720:Severity of Illness Index; D020775:Thoracic Surgery, Video-Assisted