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The objective of the present study was to assess the physical fitness of patients after apical resection and partial apical pleurectomy for the treatment of primary spontaneous pneumothorax (PSP). Between 1982 and 1999, 58 patients received surgical treatment for PSP in our department. Twelve patients needed bilateral surgical intervention. At an average of 121 months after surgery (range, 16-231 months), the patients underwent follow-up assessments. Information was obtained on the basis of a questionnaire and from clinical examinations, including spirometry/body plethysmography and exercise testing with a bicycle ergometer. High-resolution computed tomography was used to identify postoperative changes of the lung apex. Forty-eight of 58 patients took part in the study, and all were found to be fully fit. High-resolution computed tomography gave evidence of new postoperative fibrocystic processes in 26 of the 31 affected apexes. One recurrence was observed (3.2%). Because apical resection cannot counteract pathogenetic mechanisms underlying parenchymal destruction and the formation of postoperative bullae among patients with a history of PSP, additional treatment of the apical pleura is necessary to prevent recurrences. Our results suggest that the physical fitness of patients with PSP can be completely restored postoperatively.

Introduction

Primary spontaneous pneumothorax (PSP) typically occurs among otherwise healthy young male subjects between 20 and 40 years of age, with no clinically apparent lung diseases,12 and is therefore of particular occupational and military medical relevance. Patients with PSP are distinct from secondary pneumothorax patients who have underlying pulmonary diseases, most commonly chronic obstructive pulmonary disease.3 The pathogenesis of PSP is thought to be related to the entry of air into the pleural space, mostly resulting from lesions of emphysematous subpleural changes ("blebs") of the lung parenchyma. Correlative of PSP without intraoperatively visible blebs, a phenomenon described by several authors [e.g., Refs 4 and 5], might be "pleural porosities" of the apical lung6 or "apical dystrophy" diagnosed with histopathologic examination.4

Insertion of a chest catheter to reexpand the lung represents the generally accepted therapy for the first episode of PSP7 and prevents clinical recurrences in 70% to 80% of cases.8-10 PSP has a tendency for recurrence of 60% after the second episode and 80% after the third episode.8 Therefore, apical resection with partial parietal pleurectomy or gauze pleural abrasion performed through video-assisted thoracoscopic surgery (VATS) has become the standard for the treatment of persistent or recurrent PSP.7,11-14 This procedure is also advocated for patients for whom no blebs were identified with intraoperative macroscopic examination.5

We conducted a retrospective study in an attempt to assess the physical fitness of patients who had received surgical treatment for PSP. The objective of our study was assessment of a feasible restriction of physical fitness evaluated as the cardiopulmonary capacity with a questionnaire, clinical examination, spirometry, and exercise testing with a bicycle ergometer. In addition, we used high-resolution computed tomography (HRCT) to evaluate postoperative morphologic changes of the lung apex and to assess their clinical relevance.

Methods

Our retrospective study included 50 male and 8 female patients who had undergone surgery for treatment of PSP in our department between September 1982 and June 1999. For 12 of the male patients, the surgical procedure had been performed bilaterally, in two cases simultaneously (through VATS). Accordingly, our study was based on a total of 70 apexes (39 on the right side and 31 on the left side). At the time of surgery, the mean age of the patients was 27.5 years (range, 17.8-45 years). Additional data are shown in Table I. Patients who were >45 years of age at the time of surgery and patients with secondary spontaneous pneumothorax that was related to the presence of a known underlying disease were excluded from the study.

The patients were asked to complete a questionnaire and to answer questions on their medical history and their current level of physical fitness. It was thus possible to identify potential predisposing factors such as cigarette smoking and genetic factors. In addition, data recorded for each patient included the number of episodes of pneumothorax and the patient's subjective assessment of his or her physical fitness and general state of health, which was rated as "excellent," "good," "moderate," or "poor."

All patients were invited to undergo a follow-up examination on an outpatient basis. The following diagnostic methods were used: (1) anamnesis and clinical evaluation (scar evaluation, neuralgia, and ventilation); (2) spirometry/body plethysmography (Masterlab, Fa. Jäger, Hoechberg, Germany), with determination of relative vital capacity and forced expiratory volume in 1 second based on age- and gender-specific normal values (percentage); (3) measurement of serum α^sub 1^-antitrypsin levels; (4) exercise testing with a bicycle ergometer for assessment of the physical fitness of all patients 5 mm in size (Figs. 1 and 2). This examination was performed by an experienced radiologist.

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