Should Thoracoscopic Surgery Be the Standard Management for Patients With Primary Pneumothorax?

Abstract

I read the article by Chen and colleagues [1Chen J.S. Hsu H.H. Tsai K.T. Yuan A. Chen W.J. Lee Y.C. Salvage for unsuccessful aspiration of primary pneumothorax: thoracoscopic surgery or chest tube drainage?.Ann Thorac Surg. 2008; 85: 1908-1913Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar] with great interest and I must say it is well designed and informative, although I think three main points should be addressed. First, although video-assisted thoracic surgery pleurectomy may be an acceptable option after the first episode of pneumothorax, I would not consider this standardized as the first line of management. The majority of these patients can be successfully treated with a small-bore intercostal drain, which carries minimal morbidity. Chee and colleagues [2Chee C.B. Abishaganaden J. Yeo J.K. et al.Persistent air-leak in spontaneous pneumothorax—clinical course and outcome.Respir Med. 1998; 92: 757-761Abstract Full Text PDF PubMed Scopus (105) Google Scholar] showed that 100% of primary pneumothoraxes with persistent air leaks for more than 7 days treated by tube drainage had resolved their air leaks by 14 days. Furthermore, 79% of those with secondary pneumothoraxes and persistent air leaks had resolved their air leaks by 14 days with no mortality. Second, I also wondered when the author believed that the air leak prolonged and justified a video-assisted thoracic surgery pleurectomy. This interval is not clearly mentioned in the article. Finally, I wonder whether the cost between a video-assisted thoracic surgery procedure and the insertion of an intercostal drain is statistically significant. Clearly in high-volume hospitals, treatment costs for primary spontaneous pneumothorax can represent a significant financial burden. ReplyThe Annals of Thoracic SurgeryVol. 87Issue 3PreviewWe appreciate very much the interest expressed by Dr Elsayed [1] regarding our article on the salvage for unsuccessful aspiration of primary spontaneous pneumothorax [2]. Elsayed [1] raised an important controversy in the management of the first episode of spontaneous pneumothorax. We agree that video-assisted thoracic surgery (VATS) should not be the standard first line of management. In the current practice, both simple aspiration and chest tube drainage (CTD) are acceptable first line managements in patients requiring intervention. Full-Text PDF