© 2006 American Thoracic Society
Video-assisted Thoracic Surgery versus Medical Thoracoscopic Talc Poudrage in Spontaneous PneumothoraxTo the Editor:The recent article by Chen and colleagues (1) is of interest in seeking to maximize the benefits of therapy for spontaneous pneumothorax. Chen and coworkers added minocycline to pleural abrasion via video-assisted thoracic surgery (VATS), with bleb resection, reducing the recurrence rate from 8 to 2%. In a journal read by pulmonologists as well as surgeons, this approach needs to be seen in the context of the current medical thoracoscopy technic. Chen and coworkers correctly mention that VATS was introduced in 1990, but overlook the many prior decades of thoracoscopic management of pneumothorax, including 13 published series of 505 patients with a 93–97% long-term success rate after thoracoscopic talc poudrage (2). This means that the potential benefit in advancing from medical thoracoscopy to VATS is only in this small 5 to 7% group of failures/recurrences. Only a randomized study comparing Chen and coworkers' approach with simple talc poudrage could provide justification for the more invasive and expensive VATS approach, which requires an operating room, an anesthesiologist, a thoracic surgeon, and general anesthesia with double lumen intubation, none of which are needed with medical thoracoscopy. Although the spectre of acute respiratory distress syndrome (ARDS) after talc has been raised, these doubts about the safety of talc were based on retrospective and not very well documented data (3). In a literature review, only two cases of acute respiratory failure out of 1,009 patients (0.2%) were found after talc treatment of spontaneous pneumothorax (3). ARDS after talc exposure appears to be related to preventable overdoses of talc (4), to concomitant surgery, or to using uncalibrated talcs with small particles (5). Most large-scale European studies failed to detect any ARDS after talc (2), including a recent prospective study of 861 patients (6). The European multicenter study on the safety of talc poudrage in malignant pleural effusion is finished, and publication of the results can be expected soon. In the continuing search for the optimal treatment of spontaneous pneumothorax, it is remarkable that the attention in surgical research is focused on pleurodesis techniques, while the resection of blebs is a routine procedure. Resection of blebs is an invasive and expensive procedure, and there is no published evidence that it reduces recurrence of pneumothorax, compared with talc pleurodesis alone. Future studies on minimally invasive techniques should focus on this issue, to rule in/out any superior result of VATS procedures over simple thoracoscopy and talc poudrage.
Harbor–UCLA Medical Center Torrance, California
Canisius Wilhelmina Ziekenhuis Nijmegen, The Netherlands FOOTNOTES Conflict of Interest Statement: Neither author has a financial relationship with a commercial entity that has an interest in the subject of this manuscript. REFERENCES
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