VATS or simple talc poudrage under medical thoracoscopy for recurrent spontaneous pneumothorax
To the Editors:,
We read with interest the paper by Rena et al. 1 published recently in the European Respiratory Journal. The authors compared two surgical techniques of pleurodesis (i.e., mechanical abrasion and apical pleurectomy). They deliberately selected patients with stage III primary spontaneous pneumothorax (PSP), according to Vanderschueren classification, and showed that mechanical pleural abrasion requiring less time to be performed was safer than apical pleurectomy. It was a well-designed randomised controlled study answering an editorial 2 encouraging more scientific evaluation of video-assisted thoracic surgery (VATS).
However, such a study raises two questions. First, we are not sure that the Vanderschueren classification is still up to date to make therapeutic decisions about treatment of recurring PSP. PSP is a diffuse disease of the pleura as recently and elegantly shown by Noppen et al. 3. We agree that the pathophysiology of PSP remains poorly understood but we have enough data showing that blebs and bullae, or size of blebs or bullae, are not a real risk factor for PSP as restated by Rena et al. 1. The staging of PSP, as classified by Vanderschueren by looking macroscopically at the visceral pleura, implies some continuum in the process of PSP development. This implies that the higher the stage of PSP, the greater the risk of relapse in case PSP. Such a concept has never been proven at all after more than 25 years 4. Secondly, VATS using these two techniques of pleurodesis has the same long-term recurrence rate of pneumothorax (i.e. about 5%) as medical thoracosocopy with talc poudrage, as shown in another randomised controlled trial 5. Medical thoracoscopy is a simple and minimally invasive technique, performed under local anesthesia in a simple endoscopy suite, which does not require general anesthesia and double lumen tube intubation, making this technique much more cost-effective; with a cost of about a third of VATS, as suggested by Schramel et al. 6. Rena et al. 1 did not consider talc as an appropriate pleurodesis agent to prevent recurrence of pneumothorax. Such an assertion is based on guidelines and not on real scientific evidence. For a century, the talc used in Western Europe has been shown to be safe in many thousands of patients 7, contrary to the talc currently used in the UK or USA. European talc is safe and is the best sclerosing agent currently available to produce pleurodesis, as shown experimentally 8. It does not produce systemic dissemination of particles, contrary to the talc used in American studies 9. It has recently been shown to be well tolerated in a large European prospective study involving patients in much worse condition of health than PSP as they suffered from pleural involvement of metastatic malignant tumours 10.Using large-particle talc, poudrage under thoracoscopy is a safe and cost-effective procedure to prevent relapse of PSP, as demonstrated by the most extensive studies on pneumothorax management to date 11, 12. The need for a phase III randomised study comparing surgical pleurodesis and thoracoscopy talc pleurodesis is warranted to definitively select the best management of recurrent spontaneous pneumothorax.
Statement of interest
None declared.
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