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Long-term follow-up of thoracoscopic talc pleurodesis for primary spontaneous pneumothorax

Thoracic Surgery, Schillerhoehe Hospital, Gerlingen, Germany.

To the Editors:

We read with great interest the recent article by Györik et al. 1, which presented their long-term experience of primary spontaneous pneumothoraces (PSPs) treated by spontaneous breathing thoracoscopy and talc pleurodesis, and would like to invoke a more conscious use of talc pleurodesis.

Talc represents the most reliable sclerosing agent for pleurodesis currently available in the clinical setting. However, we question the practice to treat all PSPs with persisting air leak of >48 h or simple recurrences with talc pleurodesis. To us, this proceeding seems a little bit like breaking a butterfly upon a wheel.

PSPs occur typically in young, thin and tall males and females aged <30 yrs 2. Many of these are smokers, predisposing this group for developing lung cancer with a probability of 7.7% and 5.7% in males and females, respectively 3. In our opinion, a wide use of talc pleurodesis in this young patient group unjustifiably increases the complexity and morbidity of potential later operations for lung cancer in the future. Additionally, talc has been shown to disseminate into neighbouring organs, such as pericardium, mediastinum, contralateral lung and liver 4, 5, inducing potentially carcinogenic granuloma tissue. We hypothesise that the authors applied talc in their patients to compensate for the high number of missed blebs and bullae that were not treatable during spontaneous breathing thoracoscopy, resulting in a formidably low recurrence rate of only 5%. The authors' findings have to be compared with video-assisted thoracoscopy, which represents an established treatment modality affording identification and treatment of 90 and 100%, respectively, of all pulmonary blebs or bullae by pleural abrasion and wedge resection with similar long-term results 6, thereby avoiding the use of talc.

The British Thoracic Society guidelines also recommend that talc pleurodesis should not be considered as initial treatment for PSP requiring surgical intervention. Open thoracotomy or video-assisted thoracoscopy with wedge resection and pleurectomy is the first-choice treatment for PSP and, indeed, secondary pneumothorax 7. The American College of Chest Physicians has the same recommendation: the instillation of sclerosing agents is only acceptable in patients who wish to avoid surgery and for patients who present increased surgical risk 8.

As thoracic surgeons we have the responsibility to preclude potential hazards for our patients that are caused by our own actions. The light-hearted employment of talc represents, in our view, such an avoidable hazard, for which we all have to carry the can with our patients.

REFERENCES

1. Gyorik S, Erni S, Studler U, Hodek-Wuerz R, Tamm M, Chhajed PN. Long-term follow-up of thoracoscopic talc pleurodesis for primary spontaneous pneumothorax. Eur Respir J 2007;29:757–760.[Abstract/Free Full Text]
2. Primrose WR. Spontaneous pneumothorax: a retrospective review of aetiology, pathogenesis and management. Scott Med J 1984;29:15–20.[Web of Science][Medline] [Order article via Infotrieve]
3. Jemal A, Tiwari RC, Murray T, et al. Cancer Statistics, 2004. CA Cancer J Clin 2004;54:8–29.[Abstract/Free Full Text]
4. Ferrer J, Montes JF, Villarino MA, Light RW, García-Valero J. Influence of particle size on extrapleural talc dissemination after talc slurry pleurodesis. Chest 2002;122:1018–1027.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
5. Montes JF, Ferrer J, Villarino MA, Baeza B, Crespo M, García-Valero J. Influence of talc dose on extrapleural talc dissemination after talc pleurodesis. Am J Respir Crit Care Med 2003;168:348–355.[Abstract/Free Full Text]
6. Lang-Lazdunski L, Chapuis O, Bonnet PM, Pons F, Jancovici R. Videothoracoscopic bleb excision and pleural abrasion for the treatment of primary spontaneous pneumothorax: long-term results. Ann Thorac Surg 2003;75:960–965.[Abstract/Free Full Text]
7. Henry M, Arnold T, Harvey J. BTS guidelines for the management of spontaneous pneumothorax. Thorax 2003;58: Suppl. 2 ii39–ii52.[Free Full Text]
8. Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest 2001;119:590–602.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]

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