Is surgery the choice for treatment for first presentation of pneumothorax?

Primary spontaneous pneumothorax (PSP) usually occurs in young adult males, and it often recurs after treatment. In general, initial pneumothorax is treated conservatively by observation, simple aspiration, and chest tube treatment, whereas recurrent pneumothorax is treated using video-assisted thoracoscopic surgery (VATS). Accordingly, many international guidelines do not recommend surgery for initial pneumothorax unless there is persistent leakage of air (1). In the recent years, some thoracic surgeons tend to offer VATS to patients on their first presentation of PSP; however, their judgements have been made on a case by case basis without supporting evidence, and thus the optimal treatment for initial pneumothorax is still controversial (2).