Shinshu Med J, 65⑶：163～170, 2017

Outcomes of Surgically Treated Pneumothorax
in Patients with Interstitial Pneumonia
Kentaro Miura1）＊, Ryoichi Kondo1） and Yoshiaki Kitaguchi2）
1） Department of Thoracic Surgery, National Hospital Organization Matsumoto Medical Center
2） First Department of Internal Medicine, Shinshu University School of Medicine

Background : Pneumothorax with interstitial pneumonia (IP) is a refractory and life-threatening disease. The
aim of the study was to clarify the benefits of surgical treatment of initial-onset pneumothorax in patients withIP.
Methods : The medical records of 37 patients with IP who developed initial-onset pneumothorax were retro­
spectively reviewed. Two groups of patients were analyzed : a surgical treatment group (n＝20) and a non-sur­gical treatment group (n＝17). The clinical characteristics of the two groups were compared. Risk factors for re­
spiratory complications in hospital were assessed by univariate and multivariate logistic regression analyses.
Results : A Respiratory complications in hospital in the surgical treatment group included two patients who de­veloped bacterial pneumonia ; however, no patient developed acute exacerbation of IP. The location of air leak­age was determined during surgery in 19 of the 20 (95 %) patients. Air leakage developed from the bulla in 18
patients and from a crack of the lung parenchyma in one patient. Univariate and multivariate logistic regression
analyses showed that surgery was independently associated with a significantly lower risk of respiratory com­plications in hospital (hazard ratio [HR]＝0.115, p＝0.022).
Conclusion : Surgical treatment yielded relatively better results than non-surgical treatment in patients with IP
who develop initial-onset pneumothorax. Surgical treatment should be considered for IP patients who develop
pneumothorax. Shinshu Med J 65 : 163―170, 2017
(Received for publication December 13, 2016 ; accepted in revised form February 1, 2017)
Key words : pneumothorax, interstitial pneumonia, acute exacerbation, surgical treatment
Abbreviations : IP, interstitial pneumonia ; ISDs, immunosuppressive drugs ; ECOG, Eastern Cooperative Oncolo­gy Group ; PS, performance status ; KL-6, serum Krebs von den Lungen-6 ; LTOT, long-term oxygen therapy ;CT, computed tomography ; VATS, video-assisted thoracic surgery ; IIP, idiopathic interstitial pneumonia

Ⅰ Introduction

and their morbidity and mortality rates are high2）.
As excursive continuation of chest tube drainage

Pneumothorax with interstitial pneumonia (IP) is acarries a risk of empyema, surgery or pleurodesis is

life-threatening condition, with a frequency of 3.7

considered for some patients. However, these ag­

1）%-7.6 % . Because patients with pneumothorax withgressive treatments may result in the acute exacer­

IP have hard lungs and poor compliance, and be­bation of IP, and decision on timing is difficult. Al­

cause they often use steroids or immunosuppressive

though studies have reported the effectiveness ofdrugs (ISDs), this condition is often refractory topleurodesis in patients with pneumothorax withtreatment. Treatment of these patients is difficultIP3）-8）, fewer studies have assessed the effectiveness＊Corresponding author : Kentaro Miura
Department of Thoracic Surgery, Shinshu University
Hospital, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
E-mail : kmiura@shinshu-u.ac.jp

No. 3, 2017of surgical operations9）10）. Relatively little is known
about the comparative safety and effectiveness ofsurgical treatment and non-surgical conservative
treatment of pneumothorax with IP. This study there­163

Miura・Kondo・Kitaguchi

fore analyzed the benefits of surgical treatment inlungs was assessed by chest X-ray.
Pleurodesis was performed by injecting picibanil

these patients, with the goal of optimizing strategies
for the management of pneumothorax with IP.
ⅡAMaterials and Methods

Selection of patients and variables(OK-432) into the chest drainage tube, followed byclamping of the tube for approximately 30–60 min­utes and release of the clamp.
C

Respiratory complications in hospital

The medical records of all patients with initial-on­

Bacterial pneumonia and exacerbations of IP inset pneumothorax with IP, who were seen at Nation­

hospital were diagnosed and distinguished by chestal Hospital Organization Matsumoto Medical Centercomputed tomography (CT) and by clinical indica­from January 2000 to December 2013, were retro­tions of inflammation, including white blood cell

spectively reviewed. Clinical data recorded included

count and serum concentration of C-reactive pro­patient age, sex, smoking history, Eastern Coopera­

tein. Sputum culture was used to diagnose some pa­tive Oncology Group (ECOG) performance status

tients.

(PS), serum Krebs von den Lungen-6 (KL-6) con­D

Statistical analysis

centrations, receipt of long-term oxygen therapy

The distribution of numerical data in the two(LTOT), regular treatment with steroids and/or

groups was assessed with Bartlett’s test. Normally

ISDs, history of pulmonary fungus disease, and clas­

distributed variables were compared using paramet­sification of IP. The patients were categorized into

ric Student’s t-tests, whereas non-normally distrib­

two groups, those treated surgically and those treat­uted variables were compared using nonparametriced non-surgically, with the latter including patientsMann-Whitney U-tests. Categorical variables were

who underwent pleurodesis or chest tube drainage.

compared by chi-squared tests. Univariate and mul­

Clinical outcomes and in-hospital complications weretivariate logistic regression analyses were performed

compared in the two groups. The relationships be­to identify risk factors for in-hospital respiratory

tween respiratory complications in hospital and pa­

complications. Variables with P-values < 0.05 on uni­

tient demographic and clinical characteristics werevariate analyses were included in the multivariate

evaluated. This study was approved by the institu­

model. All statistical analyses were performed using

tional research ethics committee of National Hospital

SPSS version 23 software (Chicago, IL, USA), with

Organization Matsumoto Medical Center in August

P-values < 0.05 considered statistically significant.

9, 2016 (approval number 28-13).
B

Ⅲ

Methods of treatment
All of the included patients were admitted to hos­A

Results

Clinical features of the patientspital just after onset of pneumothorax, with chest

From January 2000 to December 2013, 37 patientstube drainage performed immediately upon admis­

admitted to the National Hospital Organization Mat­sion.

sumoto Medical Center, Matsumoto, Japan, experi­

Surgical treatment was performed via thoracoto­

enced first episodes of pneumothorax with IP ; Table

my or video-assisted thoracic surgery (VATS). Fail­1 shows their demographic and clinical characteris­ing lesions were treated by bulla resection using sta­tics. Of these 37 patients, 33 (89.2 %) experienced id­pling instruments, suture repair, heat ablation using

iopathic interstitial pneumonia (IIP), three (8.1 %) de­a ball chip for electrocoagulation, and ligation. Fibrin

veloped rheumatoid arthritis-related IP, and one (2.7

glue was used to repair lesions in all patients. A sin­%) developed drug-induced IP. Serum KL-6 concen­

gle-lumen chest drainage tube was inserted andtrations were elevated in 17 patients (45.9 %) just be­continually suctioned at −10 cmH2O pressure. Priorfore the onset of pneumothorax, 17 (45.9 %) received

to removal of the chest draining tube, a 12-hour

LTOT and 18 (48.6 %) were regularly treated withclamp test was performed and non-collapse of thesteroids and/or ISDs. Twenty patients (54.1 %) un­

164

Shinshu Med J

Vol. 65

Pneumothorax surgery in patients with interstitial pneumonia
Table 1

Clinical features of all included patients
Numbern＝37

Variables
Age (mean ± SD)
Gender, male/female
ECOG Performance Status

70.9±8.8
31/6

0/1/2/3/4
Smoking history, ＋/－Serum KL-6 at diagnosis, higher than the normal range ( ≧500 U/ml)/normal
LTOT, ＋/－
Regular treatment with steroid and/or ISDs, ＋/－

7/11/7/9/3
13/24
17/20
17/20
18/19
11/26

History of pulmonary fungus diseases, ＋/－Classification of IP
IIP
Others (Rheumatism/Drug-induced)
Operation/Pleurodesis/Drainage only

33
4(3/1)
20/5/12Abbreviations : ECOG, Eastern Cooperative Oncology Group ; KL6, Krebs von den Lungen-6 ; LTOT,
long-term oxygen therapy ; ISDs, immunosuppressive drugs ; IP, interstitial pneumonia ; IIP, idiopathic in­
terstitial pneumonia.

Table 2Clinical characteristics of patients in the surgical and non-surgical treatment groups

Age (mean±SD)
Gender, male/female
ECOG Performance Status
0/1/2/3/4
Smoking history, ＋/－Serum KL-6 at diagnosis (mean±SD）
LTOT, ＋/－
Regular treatment with steroid and/or ISDs, ＋/－History of pulmonary fungus diseases, ＋/－Classification of IP, IIP/Others
Respiratory complicatio n in hospital, ＋/－Bacterial pneumonia
IP exacerbation
Death in hospital, ＋/－Respiratory failure caused by pneumonia

Surgical treatment
Yes (n＝20)

No (n＝17)

p-value71.2±8.517/3

70.8±9.2
14/3

0.9
0.83

5/8/3/4/0
7/13
784.4±399.1

2/3/4/5/3
6/11
616.6±467.0

0.15
0.99
0.31

12/8
7/13

5/12
6/11

0.06
0.99

3/17
17/3
2/18
2
0
0/20
0

7/10
16/1
10/7
7
3
8/9
8

0.07
0.37
<0.01

<0.01

Abbreviations : ECOG, Eastern Cooperative Oncology Group ; KL-6, Krebs von den Lungen-6 ; LTOT,
long-term oxygen therapy ; ISDs, immunosuppressive drugs ; IP, interstitial pneumonia ; IIP, idiopathic in­
terstitial pneumonia.

derwent surgical treatment and 17 (45.9 %) werely and non-surgically treated groups. The rates oftreated non-surgically ; of the latter, five patients un­

in-hospital complications (p<0.01) and deaths (p<0.01)

derwent pleurodesis, and the remaining 12 under­

were significantly higher in the non-surgical than inwent only chest tube drainage.

the surgical treatment group. Two surgically treatedBpatients developed bacterial pneumonia as respirato­

Comparative clinical features of the surgicaland non-surgical treatment groups

ry complications, whereas 10 non-surgically treated

Table 2 shows the clinical features of the surgical­

patients developed respiratory complications, with

No. 3, 2017165

Miura・Kondo・Kitaguchi
Table 3
Therapy

Detailed clinical records of patients who experienced respiratory complications in hospital
Respiratory

Age Gendercomplication

ECOG
PS

FungusClassification
of IP

Smoking

KL-6

Steroid/

Death in

ISD

hospital－－－－

Total durationof drainage(days)

1

Operation

Pneumonia

77

Ｍ

3

0

IIP

never

400

2
3

Operation
Drainage only

Pneumonia
Pneumonia

87
74

Ｍ
Ｆ

2
3

0
1

IIP
IIP

never
never

553
333

28
15

－

＋

4

4

Drainage only

Pneumonia

76

Ｍ

2

0

IIP

never

392

Steroid＋95

Steroid
－

＋
－

30
30
35※

5

Drainage only

Pneumonia

66

Ｍ

4

1

IIP

never

480

6
7

Drainage only
Drainage only

IP exacerbation
IP exacerbation

56
63

Ｍ
Ｍ

0
3

1
1

IIP
IIP

former
never

747
2180

－

＋

8

Drainage only

Pneumonia

68

Ｆ

4

0

IIP

never

unknown

－

＋

23

9

Drainage only

Pneumonia

56

Ｍ

2

1

IIP

former396

Steroid

＋

21§

10

Pleurodesis

Pneumonia

79

Ｍ

4

0

IIP

former

450

ISD

＋

47

11
12

Pleurodesis
Pleurodesis

Pneumonia
IP exacerbation

75
77

Ｍ
Ｍ

3
1

0
0

IIP
IIP

never
former587
510

Steroid
－

＋
－

30
20

Abbreviations : IP, interstitial pneumonia ; ECOG, Eastern Cooperative Oncology Group ; IIP, idiopathic interstitial pneu­
monia ; KL-6, Krebs von den Lungen-6 ; ISDs, immunosuppressive drugs※ Bilateral pneumothorax§Recurrence of pneumothorax and reinsertion of a chest drainage tube.
Table 4

Clinical features of the surgical treatment group
Variables

NumberDuration from onset of pneumothorax to the operation, mean days (range)
VATS/Thoracotomy, nOperation methods
Bulla resection, nSutural repair, nAblation only, nLigation, nOperation time , minutes (mean±standard deviation of the mean)
Location of air leakage, bulla/crack/unknown, n
Durations of drainage after operation, mean days (range)
Recurrence within 30 days, n (%)
Respiratory complication after operation, n (%)
Bacterial pneumonia, n23.0 (8-60)
13/7
10
5
4
1
63.0±17.8
18/1/14.7 (2-21)
2 (10 %)
2 (10 %)
2

Abbreviations : VATS, video-assisted thoracic surgery ; IP, interstitial pneumonia

eight of the latter group dying of respiratory compli­

pneumothorax to surgery was 23 days (range, 8-60

cations. Table 3 shows the detailed clinical records ofdays) and the mean operation time was 63.0 minutes.

patients with in-hospital respiratory complications.

The chest drainage tube was removed an average

Of the five patients who underwent pleurodesis,

4.7 days after surgery. Only one patient experienced

three (60 %) responded and were cured. However,prolonged air leakage, requiring 21 days for tube re­bacterial pneumonia developed in two patients andmoval. The location of air leakage was detected in­

IP became exacerbated in one patient. Two patientstraoperatively in 19 (95 %) patients, occurring from

who underwent pleurodesis died of respiratory fail­the bulla in 18 patients and from a crack of the lungure caused by bacterial pneumonia in hospital.

parenchyma in one. Treatments included bulla re­C

Clinical features of the surgical treatment groupsection in 10 patients, fistula closure by manual su­

Table 4 shows the clinical features of the surgicalturing in five, bulla ablation and application of ab­treatment group. The mean time from diagnosis ofsorbable seats and fibrin spray in four, and bulla

166

Shinshu Med J

Vol. 65

Pneumothorax surgery in patients with interstitial pneumonia
Table 5

Univariate and multivariate analyses of the relationships between in-hospital respiratorycomplications and patient demographic and clinical characteristics
Variable

Univariate analysis
Age
years
GenderMale
ECOG PS
Grade2-4
Smoking history
yes
Serum KL-6 at diagnosis
higher than the normal range (≧500 U/ml)
LTOT
yes
Regular treatment with steroid and/or ISDs
yes
History of pulmonary fungus diseases
yesSurgical treatment
yes
Multivariate analysis
ECOG PS
Grade2-4
Surgical treatment
yesHR

95 % CI

p-value

1.004

0.927-1.087

0.92

0.952

0.149-6.099

0.96

2.607

1.272-5.341

0.009

1.125

0.263-4.804

0.87

1.292

0.322-5.19

0.72

2.167

0.516-9.09

0.29

1.517

0.378-6.09

0.56

0.35

0.077-1.583

0.17

0.078

0.013-0.048

0.002

2.167

0.989-4.748

0.053

0.115

0.018-0.735

0.022

Abbreviations : ECOG, Eastern Cooperative Oncology Group ; KL6, Krebs von den Lungen-6 ; LTOT, longterm oxygen therapy ; ISDs, immunosuppressive drugs

ligation in one. Two patients experienced recurrence

IP after surgery. All of the patients were dischargedof pneumothorax within 30 days after surgery ; one

from the hospital.

patient underwent repeat surgery, and the other pa­

D

Relationships between respiratory complica-

tient underwent repeat chest tube drainage. These

tions in hospital and patient backgrounds

two patients were finally cured. The patient who un­

Table 5 shows univariate and multivariate logistic

derwent repeat surgery experienced air leakage

regression analyses of factors associated with thefrom a new location, a crack in the lung parenchyma

risk of respiratory complications in hospital. Univari­near the staple line of the first operation.

ate logistic regression analysis showed that lower

Postoperative complications included bacterial

ECOG PS (hazard ratio [HR]＝2.607, 95 % confidence

pneumonia in two patients. One had undergone bullainterval [CI] 1.272-4.804, p＝0.009) and surgery (HR＝resection and developed bacterial pneumonia during0.078, 95 % CI 0.013-0.048, p＝0.002) were significant­chest tube drainage 3 days after the operation. The

ly associated with a lower risk of in-hospital respira­other patient had undergone ligation of the bulla andtory complications. Interestingly, age, sex, smoking

developed bacterial pneumonia after removal of thehistory, serum KL-6 levels, administration of LTOT,

chest drainage tube 5 days after the operation.

regular treatment with steroids and/or ISDs, andThese two patients were cured using antibiotic ther­

history of pulmonary fungal disease were not signifi­

apy. No patient experienced acute exacerbation of

cantly associated with a risk of respiratory complica­

No. 3, 2017167

Miura・Kondo・Kitaguchi

tions in hospital. Lower ECOG PS and surgical treat­

We found that almost all air leakages in patientsment were included in the multivariate analysis, whichwith pneumothorax from IP were caused by punc­

showed that surgery was independently associatedture of the bulla. Therefore, preoperative chest CT

with a lower risk of in-hospital respiratory compli­

may predict the location of air leakage. Preoperative

cations (HR＝0.115, 95 % CI 0.018-0.735, p＝0.022).

determination of air leakage may affect the placement

Because no surgically treated patient had an ECOGof the surgical wound or ports, as well as shortening

PS of 4, sub-analyses were performed to examine

the operation time. Two of our surgically treatedthe relationship between respiratory complications

patients experienced recurrence of pneumothorax

in hospital and the clinical characteristics of the 34

within 30 days after surgery. Both of these patients

surgically and non-surgically treated patients with

had undergone bulla resection using an auto suture

ECOG PS of 0-3 (n＝34), an analysis that yielded

stapler. One of these two patients underwent repeat

similar results (data not shown).

surgery, resulting in a new air leak near the staple
line from the first operation. Because lungs with IP

Ⅳ Discussion

are hard, they can be easily cracked by the auto suture

The present study found that all of the surgicallystapler. Use of fibrin glue and wide covering of thetreated patients with pneumothorax with IP werestaple line with absorbable material may prevent

cured and discharged. Univariate logistic regression

such incidents15）.

analysis showed that age, sex, smoking history, se­Another issue is related to the timing of surgery

rum KL-6 levels, administration of LTOT, regularin patients with pneumothorax with IP. One study

treatment with steroids and/or ISDs, and history ofrecommended that if air leakage is prolonged for 48

pulmonary fungal disease were not associated with ahours, surgery should be considered in patients withrisk of respiratory complications in hospital. Multi­

secondary spontaneous pneumothorax16）. Althoughvariate logistic regression analysis showed that sur­six of our patients were cured by chest tube drain­gical treatment was independently associated with a

age alone, this required an average of 14 days (range,

lower risk of respiratory complications in hospital,

9-30 days). Prolonged continuation of chest tube

suggesting the effectiveness of surgical treatment indrainage carries the risks of empyema and malnutri­

patients with pneumothorax with IP.

tion, as well as gradually worsening the general con­None of the surgically treated patients in the pres­dition of patients. Because conservative non-surgicalent study experienced acute exacerbations of IP. In

methods require a longer treatment duration to curecontrast, acute exacerbation of IP has been reported

pneumothorax with IP, additional therapy, such as

in 13.5 %-15 % of patients surgically treated for lungsurgical treatment or pleurodesis, should be consid­

cancer under general anesthesia

11）
-13）

, with these pa­
11）

ered before patient conditions worsen.

tients having a mortality rate of 80 % . Factors as­

Generally, chemical pleurodesis is ineffective in pa­

sociated with acute exacerbation of IP include pre­tients with deflated lungs, and may result in acute

operative serum KL-6, lactate dehydrogenase, andexacerbation of IP17）. In contrast, blood-patch pleu­

C-reactive protein concentrations, duration of sur­rodesis has been reported safe and effective in such

12）
-14）

.

patients8）. Autologous blood-patch pleurodesis showed

In our institution, we attempt to shorten the dura­

a cure rate of 72.7 %, with respiratory complications,tion of surgery and the duration of exposure to highin patients with pneumothorax with IP. However, 50

oxygen concentrations by shortening one-lung ven­

% of cured patients experienced recurrence of pneu­

tilation. Furthermore, to rapidly detect the location

mothorax8）. Pleurodesis may be considered first-lineof air leakage, we change video-assisted thoracic

therapy prior to surgery for patients with poor gen­surgery to small-incision thoracotomy under directeral condition and/or poor PS.

gery, and exposure to high oxygen concentrations

view.
168

Previous results have suggested that patients with
Shinshu Med J

Vol. 65

Pneumothorax surgery in patients with interstitial pneumonia

air leakage for over 48 hours be considered for sur­there was a potential for selection bias. National Hos­

gery before developing acute exacerbation of IP orpital Organization Matsumoto Medical Center is aother respiratory complications. However, surgery was

major hospital with a department of thoracic sur­

successful in some patients when performed >48

gery, and may have more patients with very severe

hours after initial development of air leakage, up to

respiratory diseases than other general hospitals.

60 days in this study. These findings suggest that

Third, we did not investigate long-term patient prog­

the optimal timing of surgery should be assessed in

nosis.

each individual patient.

In conclusion, surgical treatment should be consid­

This study had several limitations. First, this wasered in patients with pneumothorax with IP before

a single-center, retrospective study of uncontrolled

their general condition worsens owing to prolonged

design. Furthermore, there was no standard to de­continuation of chest tube drainage.

termine whether or not to perform surgery. Addi­
tional prospective studies with larger sample sizes

Conflicts of interest : none declared.

are required to confirm the present results. Second,
References
1） Franquet T, Gimenez A, Cremades R, Domingo P, Plaza V : Spontaneous pneumothorax and pneumomediastinum in
IPF. Eur Radio 1 : 108-113, 2000
2） Marshall MB, Deeb ME, Bleier JI, Kucharrczuk JC, Friedberg JS, Kaiser LR, Shrager JB : Suction vs water seal after
pulmonary resection : a randomized prospective study. Chest 3 : 831-835, 2002
3） Goldszer RC, Bennett J, VanCampen J, Rudnitzky J : Intrapleural tetracycline for spontaneous pneumothorax. JAMA
7 : 724-725, 1979
4） Macoviak JA, Stephenson LW, Ochs R, Edmunds LH : Tetracycline pleurodesis during active pulmonary-pleural air
leak for prevention of recurrent pneumothorax. Chest 1 : 78-81, 1982
5） Almind M, Lange P, Viskum K : Spontaneous pneumothorax : comparison of simple drainage, talc pleurodesis, andtetracycline pleurodesis. Thorax 8 : 627-630, 1989
6） Almassi GH, Haasler GB : Chemical pleurodesis in the presence of persistent air leak. Ann Thorac Surg 5 : 786-787,
19897） Kennedy L, Sahn SA : Talc pleurodesis for the treatment of pneumothorax and pleural effusion. Chest 4 : 1215-1222,
1994
8） Aihara K, Handa T, Nagai S, Tanizawa K, Watanabe K, Harada Y, Chihara Y, Hitomi T, Oga T, Tsuboi T, Chin K,
Mishima M : Efficacy of blood-patch pleurodesis for secondary spontaneous pneumothorax in interstitial lung dis­ease. Intern Med 11 : 1157-1162, 20119） Schoenenberger RA, Haefeli WE, Weiss P, Ritz RF : Timing of invasive procedures in therapy for primary and sec­
ondary spontaneous pneumothorax. Arch Surg 6 : 764-766, 1991
10） Nakajima J, Takamoto S, Murakawa T, Fukami T, Yoshida Y, Kusakabe M : Outcomes of thoracoscopic manage­
ment of secondary pneumothorax in patients with COPD and interstitial pulmonary fibrosis. Surg Endosc 7 : 15361540, 200911） Kim DS, Park JH, Park BK, Lee JS, Nicholson AG, Colby T : Acute exacerbation of idiopathic pulmonary fibrosis :frequency and clinical features. Eur Respir J 1 : 143-150, 200612） Shintani Y, Ohta M, Iwasaki T, Ikeda N, Tomita E, Kawahara K, Ohno Y : Predictive factors for postoperative acuteexacerbation of interstitial pneumonia combined with lung cancer. Gen Thorac Cardiovasc Surg 4 : 182-185, 201013） Mizuno Y, Iwata H, Shirahashi K, Takamochi K, Oh S, Suzuki K, Takemura H : The importance of intraoperative
fluid balance for the prevention of postoperative acute exacerbation of idiopathic pulmonary fibrosis after pulmo­
No. 3, 2017169

Miura・Kondo・Kitaguchinary resection for primary lung cancer. Eur J Cardiothorac Surg 41 : 161-165, 201214） Sakamoto S, Homma S, Mun M, Fujii T, Kurosaki A, Yoshimura K : Acute exacerbation of idiopathic interstitial
pneumonia following lung surgery in 3 of 68 consecutive patients : a retrospective study. Intern Med 2 : 77-85, 201115） Sakamoto K, Takei H, Nishii T, Miehara T, Omori T, Tajiri M, Imada T, Takanashi Y : Staple line coverage with ab­sorbable mesh after thoracoscopicbullectomy for spontaneous pneumothorax. Surg Endosc 3 : 478-481, 200416） MacDuff A, Arnold A, Harvey J : Management of spontaneous pneumothorax : British Thoracic Society Pleural Dis­ease Guideline 2010. Thorax Suppl 2 : ii18-31, 201017） Brant A, Eaton T : Serious complications with talc slurry pleurodesis. Respirology 3 : 181-185, 2001

（2016. 12. 13 received；2017. 2. 1 accepted）

170

Shinshu Med J

Vol. 65