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Primary spontaneous pneumothorax (PSP) commonly occurs in tall, thin, adolescent men. Though the pathogenesis of PSP has been gradually uncovered, there is still a lack of consensus in the diagnostic approach and treatment strategies for this disorder. Herein, the literature is reviewed concerning mechanisms and personal clinical experience with PSP. The chest computed tomography (CT) has been more commonly used than before to help understand the pathogenesis of PSP and plan further management strategies. The development of video-assisted thoracoscopic surgery (VATS) has changed the profiles of management strategies of PSP due to its minimal invasiveness and high effectiveness for patients with these diseases.
Pneumothorax is defined as air or gas accumulated in the pleural cavity. A pneumothorax can occur spontaneously or after trauma to the lung or chest wall. Pneumothorax can also be divided into tension and non-tension. A tension pneumothorax can be a medical emergency due to rising intrathoracic pressure from progressive air accumulation in the pleural space. Circulatory or respiratory failure might be developed from subsequent lung or mediastinal compression. A non-tension pneumothorax can be divided into open or close (partial) type. It is not as critical as tension pneumothorax because there is no ongoing air accumulation and hence no compression of intrathoracic organs from rising pressures (Shields et al., 2005; Noppen and de Keukeleire, 2008).
Spontaneous pneumothorax can be classified as either primary or secondary. Primary spontaneous pneumothorax (PSP), which is defined as a pneumothorax without underlying lung disease, predominantly occurs in young, thin males. It is usually caused by ruptured pleural blebs or bullae (Abdala et al., 2001; Chen Y.J. et al., 2008). Secondary spontaneous pneumothorax (SSP) usually occurs in older people with underlying pulmonary disease, such as emphysema or asthma, acute or chronic infections, lung cancer, and congenital diseases including cystic fibrosis, catamenial pneumothorax, or lymphangioleiomyomatosis (LAM) (Luh et al., 1998; 2004; Wallach, 2000).
The age-adjusted incidence of PSP is from 7.4 to 18 per 100 000 population per year in males, and from 1.2 to 6 per 100 000 population per year in females (Sahn and Heffner, 2000; Noppen and de Keukeleire, 2008). It usually occurs in tall, thin males of 10 to 30 years old. Rarely does it occur in people at the age of more than 40 years. PSP might be associated with some congenital disorders such as Marfan’s syndrome, or some environmental factors such as smoking (Roman et al., 2003). PSP usually occurs at rest. There are some precipitating factors, such as change in atmospheric pressure or emotional change. These can partially explain the cluster appearance of PSP observed in our prior reported series and literature (Alifano et al., 2007; Luh and Tsao, 2007). In our experience, in the treatment of more than 700 patients with PSP, occurrences are more common during weather changes, and midterm or final exam seasons for students. In our patients, PSP occurred during sexual activity (woman on top position) in two young males. This may be related to Valsalva maneuver, which has been regarded as a mechanism of pneumothorax or pneumomediastinum in other reported series (Birrer and Calderon, 1984). Hearing loud music has also being reported as a risk factor of PSP, which may be due to acute changes in transpulmonary pressure by exposure to sound energy (Noppen et al., 2004). Approximately 10% of patients with PSP have a positive family history. Some gene mutations, such as folliculin (FLCN, related to a rare disease, Birt-Hogg-Dube syndrome), have been found with relation to the development of PSP (Graham et al., 2005). Smoking is also regarded as a precipitating factor for PSP. The relative risk of pneumothorax ranged from 7 to 100 times higher in light to heavy smokers (Bense et al., 1987). A case-control study reviewing related epidemiological and clinicopathological data between smokers and non-smokers with PSP showed that more severe bronchiolitis and a higher recurrence rate of pneumothorax occur in smokers (Cheng et al., 2009).
Most authors believe that PSP results from spontaneous rupture of a subpleural bleb or bulla (van Schil et al., 2005). However, only a portion of patients with PSP could be found with blebs or bullae in imaging or at the time of surgery (Mitlehner et al., 1992; Amjadi et al., 2007). Other mechanisms may be considered, such as increase in pleural porosity secondary to inflammation (Ohata and Suzuki, 1980). The development of bullae, blebs, or pleural porosity might be related to many factors, such as distal airway inflammation, distal bronchial tree anomaly, disorders of connective tissue formation, local ischemia, and malnutrition (Noppen and de Keukeleire, 2008).
Spontaneous hemopneumothorax (SHP) accounts for 0.5% to 2.6% of patients with spontaneous pneumothorax. It is defined as air and blood (>400 ml) accumulation in the pleural cavity without underlying pulmonary disease or chest trauma within the previous 48 h (Wu et al., 2002; Luh and Tsao, 2007). The most probable origin of bleeding is the aberrant blood vessels which come from the chest wall and grow into the pleural lesions (bullae or blebs) of the lung through the adhesion band (Hsu et al., 2005). This phenomenon has been proved by pre-operative angiography for patients with SHP (Tsukioka et al., 1989). These vessels are usually torn when recurrent PSP with collapsed lung tears the pleural adhesion, which has been observed in over 80% of patients in some reported series undergoing bullectomy through video-assisted thoracoscopic surgery (VATS) (Sharpe et al., 1995; Luh and Tsao, 2007). The bleeders could also arise from the surface of ruptured bullae (Sasai and Shioda, 1995; Wu et al., 2002).
PSP usually occurs at rest, and presents with acute onset of local pleuritic chest pain accompanied by shortness of breath. This pain may be mild or severe, sharp and steady ache in character, and usually resolves within 24 h even though pneumothorax still exists (Noppen and de Keukeleire, 2008). On physical examination, decreased breath sounds on auscultation, decreased chest wall movement on inspection, hyper-resonance (tympanic) on percussion, and reduced tactile fremitus on palpation of the chest are most often detected in patients with large pneumothorax (free air occupies more than 15% to 20% area of hemithorax) (Shields et al., 2005). Reflex tachycardia can be found in most patients in response to discomfort or circulating or respiratory compromise. Tension pneumothorax should be suspected if severe tachycardia, cold sweating, hypotension, or cyanosis has developed. Blood gas analysis in patients with large pneumothoraces may reveal increased alveolar-arterial difference in oxygen partial pressure (PA-aO2) due to increased intrapulmonary shunt from the collapsed lung (Cottrell, 2003). Re-expansion pulmonary edema may occur in some PSP patients after undergoing chest tube insertion and drainage procedures. This complication, being rare, but life-threatening, arises from rapid pulmonary re-expansion after decompression (Schmidt-Horlohe et al., 2008). Young age, large and persistent (usually >24 h) pneumothorax, and rapid expansion of the lung are risk factors for this complication.
Most PSP cases are confirmed by upright posteroanterior chest radiograph, which can be used to assess the pneumothorax size with good accuracy (Noppen et al., 2001). A pleural line with or without an air-fluid level can be seen in the chest radiograph, but sometimes it is difficult to detect these signs, especially in patients with small pneumothoraces, emphysema, or poor exposure of the film. Expiratory chest radiographs have no diagnostic value for patients with PSP (Bradley et al., 1991).
Computed tomography (CT) of the chest can be used to detect patients with small pneumothoraces (less than 15% area of hemithorax). In addition, CT can provide more detailed information to assist in the subsequent management. Findings which can be noted include the number, size, and location of bullae/blebs (ipsi- or contra-laterally), as well the possibilities of pleural adhesion, pleural fluid accumulation, and possible underlying pulmonary diseases (Luh and Tsao, 2007). For more than 90% of patients with PSP, pathological lung changes can be detected by CT. The most common type is few (n<5) and small (<2 cm in diameter) blebs, followed by mixed blebs and bullae (>2 cm in diameter). Pure large bullae are found in less than 20% patients with PSP. On the other hand, in only one-third of patients with PSP will the bullae be seen in the chest film (Mitlehner et al., 1992). Over 85% of patients with visible bullae during VATS could be detected pre-operatively by CT scan (Sihoe et al., 2000). Similar results were also observed in our clinical experience (Luh et al., 2004). The apical bullae/blebs shadows on the CT scan should be differentiated from the normal ‘apical lines’ (Guimaraes et al., 2007). More than 50% of patients with PSP have contralateral blebs/bullae, and about a quarter of them will develop a contralateral pneumothorax (Mitlehner et al., 1992; Sihoe et al., 2000; Chou et al., 2010). CT scanning can also be used to predict the risk of recurrence of patients with PSP, allowing preemptive surgical intervention in selected patients (Mitlehner et al., 1992). Thus, we have used pre-contrast high resolution CT (HRCT) as a routine procedure for patients with PSP (Chen J.S. et al., 2008). However, some prior studies revealed that the existence and number of bullae/blebs on CT were not associated with the risk of recurrence (Ouanes-Besbes et al., 2007).
Therapeutic options include bed rest, oxygen supplementation, manual aspiration, chest tube drainage, and thoracoscopic and surgical interventions (Al-Qudah, 2006). A small (<15%) pneumothorax in an otherwise healthy patient can be observed and supplied with oxygen inhalation, which can facilitate the reabsorption of air in the pleural cavity up to four-fold faster (Shields et al., 2005). The risk of recurrence is estimated to be 20%–50%. The effectiveness of simple aspiration for patients with PSP can be assessed by taking chest radiograph 6 h later. Larger (>15%) pneumothoraces can be treated by simple aspiration with an intravenous or thoracentesis catheter, or drainage with pigtail catheter or chest tube. Simple aspiration is more effective (in about two thirds) for patients with small or moderate pneumothoraces (Chen J.S. et al., 2008).
For patients with larger pneumothoraces, recurrent attacks, or larger volumes of aspirated pleural air (>30%), more aggressive therapies such as chest tube drainage or surgery should be considered (Chambers and Scarci, 2009).
Chest tube drainage can be effective in about 85% to 90% of patients on the first episode of PSPs. However, probabilities of recurrent PSPs can be increased up to 50% after the first recurrence, and 85% after the second recurrence (Qureshi et al., 2005). A recent evidence-based medicine (EBM) review found no significant difference between simple aspiration and intercostal tube drainage with regard to immediate success rate, early failure rate, duration of hospitalization, one-year success rate, and number of patients requiring pleurodesis at one year. Simple aspiration does not require hospitalization, compared with intercostal tube drainage (Wakai et al., 2007; Zehtabchi and Rios, 2008).
A chest tube can be connected into the Heimlich one way valve or water-seal system. Large-bore chest tubes are required for PSP patients who are mechanically ventilated, or require drainage of viscous pleural liquids. Smaller-bore tubes may be adequate in patients with limited production of pleural air or of free-flowing pleural liquid (Baumann, 2003). Negative pressure suction applied on the drainage system should be used cautiously to prevent the possible complication of re-expansion lung edema (Light, 1990). Chest tubes can be removed successfully at either end expiration or end inspiration, and potentially as soon as less than 200 ml/fluid output per day is achieved (Baumann, 2003). Talc pleurodesis through a chest tube or medical thoracoscopy under local anesthesia is superior to conservative treatment by chest tube drainage only in cases of PSP that fail after simple aspiration (Tschopp et al., 2002). However, recurrences may still occur in over half of these patients undergoing talc pleurodesis only (Oransky, 2007). Hence, we use talc pleurodesis in combination with bullae/blebs resection through VATS for selective patients with PSP (Luh et al., 2004). Unfortunately, talc has been prohibited for the sake of safety in Taiwan since 2000. However, recent clinical trials have proved the safety and minimal adverse effects of talc pleurodesis in the management of patients with pneumothorax (Hunt et al., 2007; Tschopp et al., 2009).
Surgical management of PSP is usually indicated in patients with recurrent ipsilateral pneumothorax, first episode with occupational risk or persistent air-leakage (more than 5 to 7 d), or prior contralateral pneumothorax (Gossot et al., 2004; Shields et al., 2005). A first episode of a PSP is treated by observation if the area of pneumothorax is <20% or by simple aspiration if >20%, but recurrences are frequent. For recurrent or persisting pneumothorax, a more invasive surgical approach is indicated (van Schil et al., 2005). The procedure can be approached through open thoracotomy or VATS (Luh and Liu, 2006).
There are two objectives in the surgical management of pneumothorax. The first widely accepted objective is resection of blebs or the suture of apical perforations to treat the underlying defect. The second objective is to create a pleural symphysis to prevent recurrence (Morimoto et al., 2002; Klopp et al., 2007). There is nearly zero mortality and very low major morbidity with either VATS or open approaches. Postoperative complications are low (5%–10%), and usually minor and self-limited, including prolonged air-leakage, pleural effusion or hemorrhage, wound infection or hematoma, pulmonary atelectasis or pneumonia (Gossot et al., 2004; Luh et al., 2004; Sawada et al., 2005; Ben-Nun et al., 2006).
The traditional open approach has gradually been replaced by minimally invasive VATS in the diagnosis and treatment for patients with various intrathoracic diseases, including the treatment of PSP (Luh and Liu, 2006). The outcomes of VATS for patients with PSP are very good compared to conservative treatment and equal to those of open thoracotomy (Sedrakyan et al., 2004; Sawada et al., 2005). The VATS approach has the benefits of less postoperative pain, better wound cosmetics, shorter hospital stay and duration of drainage, better functional recovery, better short and long term patient satisfaction, and equivalent cost-effectiveness to the open approach (Ben-Nun et al., 2006; Vohra et al., 2008). A systematic review of 12 randomized trials including 670 patients revealed that VATS was associated with a shorter hospital stay, less pain or use of pain medication than the open procedure in five of the seven trials, and fewer recurrences than the pleural drainage in two trials (Sedrakyan et al., 2004). At three-year follow-up, 97% of the VATS group patients considered themselves completely recovered from the operation, compared with only 79% in the thoracotomy group (P<0.05). Chronic or intermittent pain, requiring the use of analgesics more than once a month, was experienced by 90% of the thoracotomy group patients and 3% of the VATS group patients. In addition, 13% of the thoracotomy group patients required clinical pain management (Ben-Nun et al., 2006; Olavarrieta and Coronel, 2009). Therefore, VATS is recommended as the first-line surgical treatment for patients with recurrent PSP or first episode of PSP (Sawada et al., 2005; Olavarrieta and Coronel, 2009). However, the recommendation can only be graded as B or C as there have been only a limited number of patients in relevant randomized trials (van Schil and de Vos, 2004).
The risk of postoperative recurrence requiring re-operation for the VATS and surgical groups varies in different reported series. Gossot et al. (2004) reported a low recurrence rate (3.6%) during a mean 36.5 months follow-up period after VATS and none of them required re-operation. VATS bullae/blebectomy, pleurodesis, and pleurectomy have been proven to be as effective as the open procedure (Sedrakyan et al., 2004). However, re-operation following VATS is more often required than that after open thoracotomy (Tomasdottir et al., 2007), with a higher rate of both late recurrent pneumothoraces and prolonged early postoperative air-leakage. A four-fold increase in the recurrence of pneumothorax following VATS pleurectomy (as compared to open pleurectomy) has been reported in a meta-analysis with 4 randomized and 25 non-randomized studies (Barker et al., 2007), although a second meta-analysis of only the randomized trials did not show this difference (Vohra et al., 2008).
VATS for PSP can be accomplished mostly through three ports, but two or single port(s) with the use of single incision port laparoscopic surgery (SILS) system has been reported in recent years (Jutley et al., 2005; Gigirey Castro et al., 2010). In our experience, the two- or one-port approach can only be applied in selective cases, and the three-port approach is still preferred because the telescope and instruments are more easily manipulated. Endotracheal general anesthesia with the use of a double or single lumen endotracheal tube is still recommended by most reported series for PSP patients undergoing VATS (Sawada et al., 2005; Luh and Liu, 2006; Olavarrieta and Coronel, 2009). VATS procedures through local or epidural anesthesia for patients with PSP (the awake procedure) have been reported (Mukaida et al., 1998; Pompeo et al., 2007). However, we do not consider this kind of anesthesia to be safe and comfortable, and thus it has not been tried in our patients.
The bullae/blebs in patients with PSP can be managed through VATS by stapling and resection, no-knife stapling, suturing, or endo-loop ligation (Liu et al., 1999; Cardillo et al., 2001; Luh and Liu, 2006). Pleurodesis is usually required in addition to bullae/blebectomy for surgical management of patients with PSP. It can significantly decrease the risk of early air-leakage or late recurrence, which is especially important for patients undergoing VATS. A retrospective review concluded that blebectomy with additional chemical pleurodesis appears to have less risk of ipsilateral recurrence, but longer postoperative stay and chest tube drainage (Bialas et al., 2008). Pleurodesis has been found, in another review, to be effective in preventing postoperative recurrence of pneumothorax and has no disadvantages in terms of worsening postoperative pain or pulmonary function (Horio et al., 2002). Chemical pleurodesis by minocycline injection, which has been developed in our group (Luh et al., 1996), has been shown to be a safe and convenient procedure that can reduce the rate of recurrence after VATS in a retrospective or prospective randomized trial by colleagues (Chen et al., 2004; 2006). However, we do not routinely perform this procedure because it frequently results in intense chest pain and fever, and this additional procedure is only preserved for patients with persistent air-leakage or a higher risk of recurrence, such as multiple or huge bullae (Luh et al., 2004; Luh and Tsao, 2007; Chen Y.J. et al., 2008).
Since the surgical treatment for patients with PSP has become less invasive through VATS in recent years, there have been many published papers suggesting the use of this surgical intervention for patients with the first PSP. A quality adjusted life year (QALE) analysis for patients with first or recurrent PSP compared different treatment options, including VATS as the primary therapy, pleural drainage followed by VATS at first and second recurrences, pleurodesis followed by VATS at first and second recurrences, pleural drainage at first attack, pleurodesis at first recurrence, and VATS at the second recurrence. It was concluded that thoracoscopic surgery can be considered the treatment of choice for the first episode of PSP (Morimoto et al., 2002). A collective survey of 183 papers concluded that VATS has superior outcomes in terms of recurrence rates of pneumothorax (0–13% according to several studies for VATS vs. 22.8%–42.0% for tube thoracostomy alone), duration of chest tube drainage (CTD) (4.56 vs. 7.60 d), and mean hospital stay (2.4–7.8 d vs. 6.0–12.0 d for CTD) after first episode of PSP, compared with conservative treatment. Additionally, even if VATS is associated with an average increased cost of 408 USD, this is mitigated by the reduced length of stay and decreased pneumothorax recurrence, both resulting in a reduction of cost of 42% compared to a conservative approach (Chambers and Scarci, 2009). There are still some reported series that do not agree with the use of VATS after the first PSP. Retrospective cost effective analysis has revealed that tube thoracostomy should be used at first occurrence, followed by VATS bullae/blebectomy and pleurodesis in case of recurrence (Cook et al., 1999; Qureshi et al., 2005). However, these studies were only based on single, retrospective, and small case number analyses, and the patient satisfaction and quality of life were not considered. VATS will be expected as an option of management for patients with their first PSP. However, the management of the first PSP remains controversial because there is still little high-quality evidence to guide the decision-making (Kelly, 2009; Robinson et al., 2009).
CT is of value in the detection of pleural blebs in patients with PSP. Particular attention should be paid to the lung apices, where the majority of blebs are located. Definitive surgical treatment should be considered at the first occurrence if these morphological abnormalities were noted on CT (Choudhary et al., 2005). However, some other reported studies revealed no correlation between recurrences and anatomical status assessed by CT, and thus VATS surgery cannot be recommended after a first episode of PSP (Mitlehner et al., 1992; Jordan et al., 1997; Martinez-Ramos et al., 2007).
In addition to assessing the necessity of surgical intervention, CT scan can also be used to localize the bullae/blebs at multiple areas or unusual sites (Luh et al., 2004; Luh and Liu, 2006), and detect existence of hemopneumothorax (Luh and Tsao, 2007). These above information can help in planning surgical strategies and in explaining the indication, risks, and benefits to the patients and their families.
CT scan can also be used to detect the existence of bullae/blebs on the contralateral lung, thereby predicting the risk of contralateral PSP. Sihoe et al. (2000) reported that one-fourth of patients with contralateral blebs developed PSP in the untreated lung. On the contrary, none of the patients without contralateral blebs developed PSP. The necessity of surgical treatment of asymptomatic contralateral blebs/bullae in patients with PSP has been proven beneficial because pneumothorax on this side will develop within one and a half years for one-fifth of them (Chou et al., 2010). In addition to the CT findings, the risk of contralateral recurrence of pneumothorax can also be significantly higher in patients with a low body mass index (<18.5 kg/m2) (Huang et al., 2007).
SHP is defined as significant blood (>400 ml) and air accumulation in the pleural cavity without underlying pulmonary disease or chest trauma history in the last 48 h (Hsiao et al., 2003). SHP is an uncommon complication of PSP, with a reported incidence of 0.5%–2.6% for all patients and 4.8%–12.0% for patients undergoing surgical intervention (Sasai and Shioda, 1995; Wu et al., 2002). SHP is sometimes life-threatening and regarded as a surgical emergency (Luh and Tsao, 2007). The bleeding usually originates from the ruptured aberrant blood vessels on the surface of bullae/blebs, which adhered to the chest wall (Tsukioka et al., 1989). Earlier reports suggest that SHP can be treated with chest tube insertion (de Perrot et al., 2000), and surgical intervention is reserved for patients with massive bleeding and hemodynamic instability, persistent bleeding for more than 24 h or retained blood clots refractory to tube drainage (Hart et al., 2002). Since VATS has gradually replaced open thoracotomy as the standard surgical approach for patients with PSP, its minimal invasiveness, excellent safety, and effectiveness makes it the primary treatment for SHP (Miyazawa et al., 2002; Luh and Tsao, 2007). Treatments of SHP through VATS include controlling the bleeders, which are most commonly on the parietal pleural side, and stapling or looping the bullae/blebs, usually on the visceral pleural side near the bleeding area, to seal off the air-leakage (Luh and Tsao, 2007).
As many as 54%–88% of patients with unilateral PSP have contralateral bullae/blebs (Ikeda et al., 1988; Bertrand et al., 1996; Sihoe et al., 2000). Hence, PSP can occur bilaterally, either simultaneously or sequentially, in around 7.8%–20.0% of patients surgically treated for PSP (Baumann and Strange, 1997; Liu et al., 1999; Lang-Lazdunski et al., 2003).
For patients with simultaneously bilateral PSP, there is little to be debated about the use of bilateral VATS at the first occurrence, because the possibility of visible bullae/blebs rupture and the risk of recurrent pneumothorax are very high (Sihoe et al., 2000). However, the necessity of bilateral procedures for patients with unilateral pneumothorax with asymptomatic contralateral bullae/blebs remains controversial, even if some prior studies have proven its benefits (Chou et al., 2010). Based on our clinical experience, we do not recommend bilateral procedures for these patients even if the chest CT revealed visible bullae/blebs on the contralateral side (Chen J.S. et al., 2008). However, these patients should be more closely followed up for a longer period postoperatively. A second VATS will be undertaken once any clinical symptoms develop and CT scan proves the appearance of contralateral PSP.
Some reported series performed bilateral VATS in the supine position, instead of the traditional decubitus position, for bilateral PSP (Huang et al., 2007). Consideration of the supine position for VATS usually depends on the condition of patients and the location of the lesions. PSP patients are usually young in age with a normal lung function, and the bullae/blebs are usually located at the apical area, in which the posterior aspect is difficult to check thoracoscopically in the supine position. Moreover, there are usually dense adhesions with engorged vessels from the chest wall for patients with recurrent PSP (Chen Y.J. et al., 2008). Thus, bilateral VATS for PSP in the supine position is not necessary.
In summary, VATS is a safe and effective procedure in the treatment of bilateral PSP. Bilateral VATS is only recommended for patients with simultaneously bilateral PSP, because the incidence of recurrence, even with visible bullae, was not so high in our experience and in the literature. Bilateral VATS in a supine position should only be used in selective cases, because of possible pleural adhesion or hidden bullae on the posterior side (Chen Y.J. et al., 2008).
The development and application of new diagnostic tools, especially the high resolution CT scan, have helped to better understand the pathogenesis of PSP and influence the management. The development of the minimally invasive VATS technique has changed the profiles of traditional management strategies. However, there still exist many controversies in the selection of optimal diagnostic tools and management plans in specific cases. In the future, further evidence from more prospective randomized trials will be required to answer these questions. In addition, better minimal surgical techniques to detect and remove hidden bullae/blebs, or pleurodesis techniques with better effectiveness and less adverse effects, are still expected to improve the treatment outcomes of patients with PSP.
Introducing editorial board member: Prof. Shi-ping LUH, the author of this review, is an editorial board member of the Journal of Zhejiang University SCIENCE B (Biomedicine & Biotechnology). He obtained his MD and Ph.D from the School of Medicine of the National Taiwan University in 2000. Currently, he is a Professor of Surgery, Taiwan Chiao Tung University and Taiwan Chia-Yi University, and also the Vice Superintendent of Taiwan St. Martin de Porres Hospital, one of largest hospitals in the Chia-Yi region of Taiwan, with nearly 1000 beds total in its main and two branch hospitals. He became a Fellow of the International Congress of Surgery (ICS) in 2002 and American Congress of Chest Physicians (FCCP) in 2006. He has been a Laureate in the Marquis Who’s Who Biomedicine (2009–2010) and World Encyclopedia (2011–2012).