title: The best time for surgery on a patient with recurrent pneumothorax and undetectable culprit lesions is at the exact time air leakage is discovered: a case report.
abstract: BACKGROUND
  One cause of recurrent spontaneous pneumothorax includes overlooking bullae during a previous surgery for pneumothorax; and the identification of the culprit lesions is necessary for prevention of recurrence.
  
  
  METHODS
  A 28-year-old man was referred to our hospital because of spontaneous right-sided pneumothorax. He underwent video-assisted thoracoscopic surgery, which did not reveal air leakage. The patient was subsequently seen at our hospital for 2 additional episodes of recurrent right-sided pneumothorax. At the third admission we observed intermittent air leakage while the patient was in the sitting position after chest drainage, and we performed surgery. An intraoperative submersion test showed air leakage dorsally from the pleural surface of S(6) and a minute culprit lesion, which were not seen at the first operation and confirmed the leakage site. The area was ligated and coated with regenerated oxidized cellulose mesh and autologous blood.
  
  
  CONCLUSIONS
  In cases of pneumothorax with repeated recurrence, the best time to perform surgery on the patient with undetectable culprit lesion is the exact time that air leakage is observed.
authors.affiliation: Division of Chest Surgery, Toho University School of Medicine, Tokyo, Japan.
authors.forename: Yousuke
authors.initials: Y
authors.lastname: Matsumoto
authors.affiliation: Division of Chest Surgery, Toho University School of Medicine, Tokyo, Japan.
authors.forename: Yoshinobu
authors.initials: Y
authors.lastname: Hata
authors.affiliation: Division of Chest Surgery, Toho University School of Medicine, Tokyo, Japan.
authors.forename: Takashi
authors.initials: T
authors.lastname: Makino
authors.affiliation: Division of Chest Surgery, Toho University School of Medicine, Tokyo, Japan.
authors.forename: Satoshi
authors.initials: S
authors.lastname: Koezuka
authors.affiliation: Division of Chest Surgery, Toho University School of Medicine, Tokyo, Japan.
authors.forename: Hajime
authors.initials: H
authors.lastname: Otsuka
authors.affiliation: Division of Respiratory Medicine, Toho University School of Medicine, Tokyo, Japan.
authors.forename: Keishi
authors.initials: K
authors.lastname: Sugino
authors.affiliation: Division of Respiratory Medicine, Toho University School of Medicine, Tokyo, Japan.
authors.forename: Kazutoshi
authors.initials: K
authors.lastname: Isobe
authors.affiliation: Division of Respiratory Medicine, Toho University School of Medicine, Tokyo, Japan.
authors.forename: Sakae
authors.initials: S
authors.lastname: Homma
authors.affiliation: Division of Chest Surgery, Toho University School of Medicine, Tokyo, Japan. aiyoda@med.toho-u.ac.jp.
authors.forename: Akira
authors.initials: A
authors.lastname: Iyoda
mesh_terms: D000328:Adult; D000388:Air; D001769:Blood; D002483:Cellulose, Oxidized / Q000008:administration & dosage*; D005260:Female; D006801:Humans; D008297:Male; D011013:Pneumonectomy; D011030:Pneumothorax / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D012008:Recurrence; D013997:Time Factors; D014014:Tissue Adhesives / Q000008:administration & dosage*
chemical_list: D002483:Cellulose, Oxidized; D014014:Tissue Adhesives
keywords: Recurrent pneumothorax; Submersion test; Video-assisted thoracoscopic surgery