In patients undergoing video-assisted thoracoscopic surgery (VATS) bullectomy for primary spontaneous pneumothorax (PSP), resection of unruptured contralateral bullae/blebs is not recommended; instead, contralateral bullae/blebs should be managed nonsurgically, said authors of a study on this subject that was recently published in Chest.

Currently, no management guidelines exist for whether or not to preemptively remove unruptured contralateral bullae and blebs during ipsilateral VATS in order to prevent recurrence of PSP. In an effort to provide guidance on this question, researchers for the current study investigated the risk factors and the annual incidence rate of contralateral PSP, and to what extent contralateral blebs/bullae might contribute to PSP recurrence.

In the current retrospective cohort study, researchers based in Incheon, South Korea, examined the medical records, radiographs, and high-resolution computed tomography (HRCT) scans of 567 patients aged 30 years and younger (89.8% male) admitted to a single medical center. All study participants had ipsilateral VATS for PSP between April 2009 and December 2019. The primary study outcome was recurrence-free survival (no contralateral pneumothorax) after hospital discharge irrespective of the type of treatment.

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Results showed that contralateral pneumothorax arose in 86 of the 567 (15.2%) patients undergoing the procedure during 51.3 months of follow-up. Recurrence-free survival rates were: 1 year, 92.2%; 5 years, 83.7%; and 10 years, 79.9%. Patients with contralateral bullae or blebs experienced higher contralateral recurrence of pneumothorax (82 of 455, 18.0%) than those without (4 of 112, 3.6%; P <.001).

The annual pneumothorax incidence rate of 4.04% seen in the cohort with contralateral bullae/blebs went up as the size of the bullae or blebs grew, ranging from 3.39% in patients with air pockets between 0 mm and 5.0 mm to 4.69% in those with bullae/blebs greater than 5.0 mm.

Study limitations included selection bias introduced by the retrospective nature of the study and a lack of paired HRCT examination results, although the authors acknowledged that HRCT-based examination in patients with no symptoms presents ethical questions. Pleural porosity, which has been linked to pneumothorax recurrence, was omitted in this study; the authors recommend addressing this subject in future research.

“Although contralateral bullae/blebs were common in patients who underwent ipsilateral VATS for PSP and were statistically significantly associated with future pneumothorax, the annual rate of pneumothorax was 4.0% in such patients, and it decreased over time. Therefore, a conservative approach on unruptured contralateral bullae/blebs is recommended,” concluded the study authors, adding that further studies on this subject were needed.


Jeong JY, Shin AY, Ha JH, et al. Natural history of contralateral bullae/blebs after ipsilateral video-assisted thoracoscopic surgery for primary spontaneous pneumothorax: a retrospective cohort study. Chest. Published online May 10, 2022. doi:10.1016/j.chest.2022.05.001