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From the Authors

¹ Centre Valaisan de Pneumologie, Montana, Switzerland. ² Service de Pneumologie, Hôpital de la Conception, Marseille, France. ³ Afdeling Longziekten, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands. ⁴ Abteilung für Pneumologie, Universitätskantonsspital, Basel, Switzerland. ⁵ Service de Pneumologie, Cliniques Universitaires UCL de Mont-Godinne, Yvoir, Belgium. ⁶ St Elisabeth ZH, Turnhout, Belgium. ⁷ Divisione di Pneumologia, Spedali Civili, Brescia, Italy

From the authors:

We would like to thank T. Pieters for his interest in our paper and take the occasion to reply to some of his questions. First, should thoracoscopic talc (TT) poudrage be proposed for the management of a first episode of primary spontaneous pneumothorax (PSP) if a simple treatment such as aspiration has failed? In our study we included all patients with PSP requiring chest-tube drainage. A subanalysis of the 28 patients who presented with a first episode of PSP would most likely show the same results, as there was no difference in any clinical characteristics between a first episode and recurrent PSP. However, it is a good question which might be answered in another study including only patients with a first episode of PSP. We definitely showed in a prospective way, that simple thoracoscopic talc poudrage under local anaesthesia is a safe (there were no complications at all) and cost-effective treatment of PSP requiring chest-tube drainage. Moreover, because of the design of the study, we did not take into account the costs of rehospitalisation for a late recurrence which were, as expected, much higher in the conservative group treated by chest tube alone. This would certainly have corroborated the findings that TT poudrage is more cost-effective than chest-tube drainage, a well accepted treatment for PSP requiring a chest tube. In other words, our study, performed with a randomised, prospective design, definitely showed that TT poudrage is superior to conservative treatment by chest-tube drainage. This is important information which has never been reported before. Schramel et al. 1 performed a different study. They compared retrospectively, in two historical series, video-assisted thoracoscopic surgery (VATS) under general anaesthesia to chest-tube drainage alone, as treatment of PSP requiring chest-tube drainage. They showed that the more expensive technique, VATS, was more cost-effective than conservative treatment. The same authors further concluded that using simple talc poudrage would have resulted in an additional 62% reduction of the cost 2. A mini-invasive technique, such as thoracoscopy with talc pleurodesis, is very effective in preventing recurrence of a spontaneous pneumothorax either for a first episode of PSP or secondary pneumothorax, even it is an old technique performed for a 100 yrs, as suggested by Weissberg and Refaely 3. We think that in today's standard of care, the patient with a first episode of PSP requiring a chest tube should be offered the choice between a treatment which importantly reduces the recurrence rate (TT), versus a treatment with a higher recurrence rate (pleural drainage), both treatments implying the same duration of hospital stay.

Secondly, we agree that there is ongoing discussion about when and how long to apply suction through the chest tube in either group. Unfortunately, there is currently no answer to this question because of lack of scientific data. We decided to use suction immediately in the TT group because it is performed in this way in all centres participating in the study, based on the idea that the sooner parietal and visceral pleural are brought in contact with each other, the better.

Thirdly, we do not agree with the comment about the method of cost calculation as proposed. Our study was a multicentre European trial conducted in five countries with different health systems and different hospital reimbursement policies. The only economically reliable method to look at the real costs was to unify the method of calculation, after having meticulously recorded all procedures material and manpower used for each patient.

Finally, although it is very easy to insert a second drain under visual control at the end of thoracoscopy, we agree that the same hole can be used for this purpose.

References

1. Schramel FMNH, Sutedja TG, Braber JCE, van Mourik JC, Postmus PE. Cost-effectiveness of video-assisted thoracoscopic surgery versus conservative treatment for first time or recurrent spontaneous pneumothorax. Eur Respir J 1996;9:1821–1825.[Abstract]
2. Noppen N. Treatment of spontaneous pneumothorax - an ongoing debate. Eur Respir J 1998;11:514–515.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
3. Weissberg D, Refaely Y. Pneumothorax: experience with 1,199 patients. Chest 2000;117:1279–1285.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Permissions Request Permissions Services Email this article to a friend Similar articles in this journal Similar articles in Web of Science Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Tschopp, J-M. Search for Related Content PubMed Articles by Tschopp, J-M.