© 2006 American Thoracic Society
Video-assisted Thoracic Surgery versus Medical Thoracoscopic Talc Poudrage in Spontaneous PneumothoraxFrom the Authors:Primary spontaneous pneumothorax (PSP) is believed to be caused by air leaks from subpleural blebs or bullae. Obliteration of leaks by thoracoscopic resection or ligation of the offending blebs is effective in preventing recurrence. Identification of all leaks is not always possible, especially when patients have diffuse, tiny subpleural bullous alterations or blebs that cannot be identified. Therefore, pleural symphysis induced either by chemical or mechanical methods reduces the rates of recurrence. Drs. Aelony and Janssen raise an important issue, which is that resection of blebs might not be indicated if adequate pleurodesis can be achieved. Thoracoscopic talc poudrage would be an attractive alternative to video-assisted thoracoscopic surgery (VATS) for treating PSP because it is less invasive and high success rates have been reported (1). However, questions have been raised concerning the safety and long-term effects of talc pleurodesis in young, healthy patients with PSP. Talc can cause pulmonary inflammation, granulation tissue formation, and acute respiratory distress syndrome (ARDS) (2). Long-term problems with talc include difficult future thoracic surgery and decreased pulmonary function (3). Talc may also induce more intense pleural adhesions than does pleural abrasion or minocycline instillation via VATS. However, when combined with bullectomy, the recurrence rates after VATS are comparable with talc poudrage, while avoiding the above complications. In our cohort of more than 400 patients with PSP, we did not observe pulmonary inflammation or ARDS after VATS bullectomy, pleural abrasion, and minocycline pleurodesis (4, 5). Patients in the minocycline group also had pulmonary function tests that were similar to those in the observation group (4). VATS is a very useful tool to detect the location of air leaks. If the leaks can be easily identified, why should we induce overwhelming inflammation involving the whole pleural cavity by talc poudrage? On the other hand, our study shows that patients with multiple blebs or no identifiable bleb during VATS have higher rates of recurrence, probably caused by overlooked small blebs or air leaks (4). In such conditions, intense pleural symphysis induced by additional minocycline pleurodesis or talc poudrage may be the favored therapy. We agree that the lung inflammation after talc poudrage could be caused by talc overdose or by using uncalibrated talc mixtures (6). With better understanding of underlying mechanisms, talc poudrage of the pleural cavity either by VATS or by medical thoracoscopy is likely to become much safer. We believe that it is time to conduct a prospective randomized trial comparing the effects of VATS versus medical thoracoscopic talc poudrage in PSP. Special attention should be focused on long-term effects because we are treating young persons with several decades of life ahead of them.
National Taiwan University Hospital Taipei, Taiwan 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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