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.
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