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A cost-effective thoracoscopic treatment strategy for pediatric spontaneous pneumothorax
C H Cook1, W S Melvin, J I Groner
1Departments of Surgery, The Ohio State University Hospitals and Columbus Children's Hospitals, N-747 Doan Hall, 410 West Tenth Avenue, Columbus, OH 43210, USA.
Insights
For pediatric primary spontaneous pneumothorax (PSP), initial nonoperative management leads to high recurrence rates. Surgery via video-assisted thoracoscopic surgery (VATS) after recurrence offers a more effective and cost-efficient strategy.
Area of Science:
- Pediatric Thoracic Surgery
- Pulmonology
- Medical Economics
Background:
- Pediatric primary spontaneous pneumothorax (PSP) shows higher recurrence rates with nonoperative treatment compared to adults.
- Video-assisted thoracoscopic surgery (VATS) presents an effective therapeutic option with reduced morbidity for PSP.
- Defining the most cost-effective VATS strategy for pediatric PSP is crucial.
Purpose of the Study:
- To determine the most cost-effective and clinically efficacious treatment strategy for pediatric primary spontaneous pneumothorax (PSP).
- To compare recurrence rates and treatment costs between nonoperative and operative management of pediatric PSP.
Main Methods:
- Retrospective review of pediatric PSP admissions at a tertiary care children's hospital from January 1991 to June 1996.
- Analysis of initial nonoperative management (tube thoracostomy, oxygen) versus operative management (VATS).
- Evaluation of recurrence rates, contralateral pneumothoraces, and associated treatment charges.
Main Results:
- Fifteen children experienced 29 PSPs; 57% had recurrence after initial nonoperative treatment, with 75% experiencing a second recurrence.
- Operative management (VATS) in eight children resulted in a significantly lower recurrence rate of 9%.
- Estimated charges for initial nonoperative therapy followed by VATS after one recurrence were $230,000, compared to $315,000 for treating all 29 pneumothoraces in the cohort.
Conclusions:
- Tube thoracostomy is recommended for the initial presentation of pediatric PSP.
- Video-assisted thoracoscopic surgery (VATS) with bleb resection and pleurodesis is the recommended strategy for recurrent pediatric PSP.
- This approach offers a cost-effective treatment plan, minimizing recurrence and associated healthcare costs.
Background:
Recent data suggest that children have a higher incidence of recurrence than adults after nonoperative treatment of primary spontaneous pneumothorax (PSP). Video-assisted thoracoscopic surgery (VATS) allows efficacious therapy with significantly less morbidity. We attempt to define the most cost-effective clinically efficacious strategy using VATS to manage pediatric PSP.
Methods:
We retrospectively reviewed all admissions to a tertiary care children's hospital for PSP between January 1, 1991 and June 30, 1996.
Results:
Fifteen children had 29 primary or recurrent PSPs. Mean patient age was 14.8 +/- 1.1 years, boy-girl ratio 4:1, median body mass index 18 (normal, 20-25), and 67% of pneumothoraces left sided. All patients were managed initially nonoperatively: 14 with tube thoracostomy drainage and 1 with oxygen alone. Of the children initially managed nonoperatively, 57% had a recurrent pneumothorax, and 50% of these patients eventually developed contralateral pneumothoraces. Nonoperative treatment for recurrence resulted in a 75% second recurrence rate. In contrast, eight children who underwent operative management had a 9% incidence of recurrence. The total for charges accrued in treating 29 pneumothoraces in these 15 patients was approximately $315,000. In the same population, the estimated charges for initial nonoperative therapy followed by bilateral thoracoscopy after a single recurrence would be $230,000.
Conclusions:
A cost-effective treatment strategy for pediatric primary spontaneous pneumothorax is tube thoracostomy at first presentation, followed by VATS with thoracoscopic bleb resection and pleurodesis for patients who experience recurrent pneumothorax.