Beyond recurrence: toward individualized clinical decision-making in spontaneous pneumothorax surgery

The surgical management of spontaneous pneumothorax, one of the most common conditions encountered by thoracic surgeons, continues to evolve. Minimally invasive surgery has significantly transformed operative approaches; however, preventing postoperative recurrence remains challenging, despite remarkable advances in thoracoscopic techniques (1). In this timely narrative review, Tsuboshima provides a comprehensive surgeon-oriented overview of the current surgical strategies for primary spontaneous pneumothorax (PSP) and selected forms of secondary spontaneous pneumothorax (SSP). In addition to standard PSP management, particular emphasis is placed on recurrence-preventive adjuncts, including staple-line coverage, pleural covering, and chemical pleurodesis, as well as disease-specific surgical approaches for lymphangioleiomyomatosis (LAM), Birt-Hogg-Dubé syndrome (BHDS), and thoracic endometriosis-related pneumothorax (TERP). Rather than attempting to comprehensively summarize the extensive literature on spontaneous pneumothorax, the author intentionally focuses on practical surgical techniques and operative decision-making directly applicable to daily thoracic surgical practice. This practical approach enhances the value of this review by prompting thoracic surgeons to rethink how they incorporate modern surgical methods into their clinical work.

In addition to summarizing individual techniques, this review illustrates a broader evolution in the clinical strategy for spontaneous pneumothorax surgery. Historically, surgical success has been primarily judged by a single endpoint: prevention of postoperative recurrence. Minimally invasive surgery has become the standard approach, and the goals of surgical management have gradually expanded. Thoracic surgeons are now expected to balance multiple priorities, such as minimizing recurrence, reducing surgical invasiveness, preserving future treatment options, and optimizing long-term disease management, particularly in patients who may experience recurrent episodes or live with lifelong disorders, including BHDS or LAM. Consequently, contemporary pneumothorax surgery should no longer be regarded simply as a technical procedure for bulla resection, but rather as a process of thoughtful clinical judgment, in which operative strategies are tailored to disease characteristics, anticipated lifetime recurrence risk, and long-term management needs.

The evolution of surgical treatments for spontaneous pneumothorax reflects a changing clinical philosophy. Over the past three decades, open thoracotomy has largely been replaced by multiportal video-assisted thoracoscopic surgery (mVATS) with the increasing use of uniportal video-assisted thoracic surgery (VATS) in selected patients (2-4). These minimally invasive approaches are associated with reduced postoperative pain, improved cosmetic outcomes, and faster recovery, thereby changing the surgical experience of patients with spontaneous pneumothorax (2-4). Technical advancements alone do not necessarily ensure superior long-term outcomes. As emphasized by Tsuboshima, recurrence prevention remains the cornerstone of surgical management for both PSP and selected forms of SSP (1). Various adjunctive strategies, including staple line coverage, pleural covering, mechanical pleural abrasion, and chemical pleurodesis, have been proposed to address the persistent risk of postoperative recurrence.

The changing focus of clinical research also reflects this evolution. Earlier investigations primarily examined whether thoracoscopic surgery could achieve recurrence rates comparable with those of thoracotomy. More recently, however, attention has shifted toward comparisons among minimally invasive approaches themselves—particularly uniportal versus multiportal VATS—with emphasis on postoperative pain, cosmetic outcomes, chest tube duration, length of hospitalization, and quality of recovery (2-4). This transition reflects the considerable success of minimally invasive surgery. At the same time, however, it raises an important question that remains relevant today (5): has the field gradually shifted its attention away from the original objective of surgery—durable prevention of recurrence?

Despite the perioperative advantages of thoracoscopic surgery, postoperative recurrence is more frequent post-VATS than post-thoracotomy, and the difference persists after propensity score adjustment. Although the retrospective design precludes causal conclusions, the findings suggest that greater technical minimalism does not automatically translate into greater durability. One possible explanation is that the wider intrathoracic exposure afforded by thoracotomy may facilitate a more comprehensive identification and treatment of occult blebs or fragile pleural lesions. A contemporary randomized comparison between thoracotomy and VATS is unlikely to be feasible or clinically acceptable. Further progress should focus on improving recurrence-preventive strategies within the framework of minimally invasive surgery while ensuring that long-term recurrence remains a core outcome when newer approaches are evaluated.

Highlighted here are the fundamental characteristics of spontaneous pneumothorax research. High-level evidence is difficult to obtain. Spontaneous pneumothorax encompasses highly heterogeneous conditions, ranging from PSP in otherwise healthy young individuals to rare inherited disorders, such as BHDS, and progressive diffuse cystic lung diseases, including LAM.

The continuous evolution of surgical techniques further complicates long-term randomized comparisons, as operative strategies may change before sufficiently mature outcomes become available. Consequently, much evidence has been obtained from retrospective cohort studies, propensity score analyses, and single-center experiences, particularly for rare diseases. This should not be regarded as a weakness of the field; it has fostered surgeon-driven innovation. Several recurrence-preventive approaches—including staple-line coverage, pleural covering, total pleural covering, and intrathoracic administration of hypertonic glucose—originated from clinical observation and technical refinement before broader validation (6-10). Collaborative prospective registries and multicenter studies are now needed to evaluate their reproducibility, durability, and applicability beyond the institutions where they were developed. Nevertheless, the role of thoracic surgeons extends beyond technical proficiency or strict adherence to an incomplete evidence base. This requires integrating the best available evidence with disease-specific characteristics, patient expectations, anticipated lifetime recurrence risk, and the potential need for future interventions. Therefore, contemporary pneumothorax surgery is not merely evidence-based; it requires evidence-informed, individualized surgical decision-making.

The importance of evidence-informed, individualized decision-making is apparent in rare forms of SSP. In BHDS and LAM, diffuse and frequent bilateral cystic lesions render complete resection neither feasible nor desirable. Therefore, surgical treatment must extend beyond the removal of the apparent source of air leakage to address the vulnerability of the remaining visceral pleura. Total pleural covering with absorbable oxidized regenerated cellulose sheets is an innovative response to this challenge and has produced favorable recurrence outcomes in single-center series (9,10). Nevertheless, these results should be interpreted in a clinical context. Patients with BHDS often undergo surgery at a relatively young age, and the risk of recurrent pneumothorax persists over a much longer lifetime than the follow-up periods available in most published studies. Similarly, LAM is a progressive diffuse lung disease in which recurrent pneumothorax may occur despite surgical intervention. Management may require pleural covering and integration of disease-modifying treatments such as sirolimus. TERP provides another example in which surgery alone may be insufficient, since postoperative hormonal therapy can form an essential component of recurrence prevention. These conditions demonstrate that the success of pneumothorax surgery cannot always be assessed solely based on whether recurrence occurs within the first few postoperative years. Durability, preservation of pulmonary and pleural functions, feasibility of future interventions, and coordination with medical treatments should also be considered. Therefore, longer follow-up, external validation, and multicenter evaluation are required before institution-specific innovations can be regarded as broadly established strategies. At the same time, the rarity and heterogeneity of these diseases mean that treatment cannot be reasonably deferred until definitive randomized evidence becomes available. Careful clinical judgment and transparent discussions with the patients are indispensable.

These considerations can be summarized as a balance between three interdependent objectives: recurrence prevention, minimal surgical invasiveness, and long-term disease management (Figure 1). Emphasizing any one objective without considering the others may produce an incomplete strategy. An aggressive pleural procedure may reduce recurrence but increase postoperative pain, bleeding, pleural adhesions, or the difficulty of future thoracic interventions. Conversely, extreme pursuit of technical minimalism may improve early recovery while providing insufficient durability in young patients with a substantial lifetime recurrence risk. The right balance differs among the initial episode of PSP in an otherwise healthy young adult, recurrent pneumothorax in a patient with BHDS, progressive diffuse cystic disease in LAM, and hormonally influenced TERP. The central task is therefore not to identify a universally superior technique, but to construct an individualized surgical strategy according to the underlying disease, recurrence pattern, patient preferences, occupational or lifestyle risks, and anticipated future treatment needs. Emerging technologies may support this transition from technique-centered to patient-centered surgery. Artificial intelligence-based imaging analysis can potentially facilitate digital pleural phenotyping by identifying the distribution and characteristics of cysts, bullae, and subtle pleural abnormalities that are difficult to quantify visually. Integrating imaging findings with age, disease type, previous episodes, operative findings, and treatment history may eventually permit more accurate recurrence risk prediction. Such models could help determine which patients require bullectomy alone, localized staple line reinforcement, wider pleural covering, or pleurodesis. Robot-assisted thoracic surgery may offer enhanced visualization and instrument precision; however, its additional value for spontaneous pneumothorax remains unproven, particularly for procedures that can be performed effectively using conventional VATS. The relevance of a new technology should therefore be judged by whether it improves recurrence control, reduces patient burden, or supports more reproducible decision-making, rather than by technical novelty alone. Technology should inform and enhance clinical judgment, rather than replace it.

Figure 1 Conceptual framework for individualized clinical decision-making in spontaneous pneumothorax surgery. Contemporary management requires balancing three interdependent objectives: recurrence prevention, minimally invasive surgery, and long-term disease management. The optimal balance varies according to disease characteristics, anticipated lifetime recurrence risk, patient preferences, and future treatment needs.

Tsuboshima’s review provides a valuable synthesis of techniques that currently define spontaneous pneumothorax surgery and illustrates how surgeon-driven innovation has addressed persistent concerns regarding postoperative recurrence. However, its broader implication is that contemporary management can no longer be reduced to a choice among bullectomy, covering, and pleurodesis. The evidence base remains imperfect because of heterogeneous disease mechanisms, rapidly evolving techniques, and rarity of several clinically important conditions. Within these constraints, thoracic surgeons must combine the best available evidence with long-term clinical perspectives and patient-specific priorities. The future of spontaneous pneumothorax surgery cannot be determined by identifying a universally superior procedure. Rather, progress relies on achieving an appropriate balance among recurrence prevention, surgical invasiveness, and long-term disease management. The most meaningful advancement will therefore be the development of evidence-informed, individualized surgical strategies adapted to each patient’s disease characteristics, lifetime recurrence risk, and anticipated future treatment needs.

Acknowledgments

We would like to thank Editage (www.editage.jp) for English language editing.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Visualized Surgery. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-0053/coif). The author has no conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Tsuboshima K. Surgical strategies for spontaneous pneumothorax: a narrative review. J Vis Surg 2026;12:11. [Crossref] [PubMed]
2. Tsuboshima K, Kurihara M, Ohashi K. New Trends in Uniportal Video-Assisted Thoracoscopic Surgery for Primary Spontaneous Pneumothorax: A Narrative Review. J Clin Med 2025;14:1849. [Crossref] [PubMed]
3. Janssen N, Franssen AJPM, Ramos González AA, et al. Uniportal versus multiportal video-assisted thoracoscopic surgery for spontaneous pneumothorax. J Cardiothorac Surg 2024;19:387. [Crossref] [PubMed]
4. Chuang JH, Hsu HH, Lin MW, et al. Evaluating postoperative recovery in uniportal versus needlescopic video-assisted thoracoscopic surgery for primary spontaneous pneumothorax: a comparable study. Front Surg 2024;11:1356989. [Crossref] [PubMed]
5. Pagès PB, Delpy JP, Falcoz PE, et al. Videothoracoscopy versus thoracotomy for the treatment of spontaneous pneumothorax: a propensity score analysis. Ann Thorac Surg 2015;99:258-63. [Crossref] [PubMed]
6. Tsuboshima K, Wakahara T, Matoba Y, et al. Pleural Coating by 50% Glucose Solution Reduces Postoperative Recurrence of Spontaneous Pneumothorax. Ann Thorac Surg 2018;106:184-91. [Crossref] [PubMed]
7. Lee S, Kim HR, Cho S, et al. Staple line coverage after bullectomy for primary spontaneous pneumothorax: a randomized trial. Ann Thorac Surg 2014;98:2005-11. [Crossref] [PubMed]
8. Yamanaka S, Kurihara M, Watanabe K. A novel dual-covering method in video-assisted thoracic surgery for pediatric primary spontaneous pneumothorax. Surg Today 2019;49:587-92. [Crossref] [PubMed]
9. Kurihara M, Mizobuchi T, Kataoka H, et al. A Total Pleural Covering for Lymphangioleiomyomatosis Prevents Pneumothorax Recurrence. PLoS One 2016;11:e0163637. [Crossref] [PubMed]
10. Mizobuchi T, Kurihara M, Ebana H, et al. A total pleural covering of absorbable cellulose mesh prevents pneumothorax recurrence in patients with Birt-Hogg-Dubé syndrome. Orphanet J Rare Dis 2018;13:78. [Crossref] [PubMed]