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From the authors

Pulmonary Medicine, University Hospital Basel, Basel, Switzerland.

We would like to thank V. Steger and co-workers for their interest in our recent article 1. The technique of talc pleurodesis for primary spontaneous pneumothorax has been applied for decades in many centres in Europe without any evidence of long-term problems 2–4. We have already discussed the question of treating primary spontaneous pneumothorax with persisting air leak for >48 h in our study. This practice at our institution has stemmed from a previous report from our hospital which showed that when an air leak persists for >48 h, the probability of spontaneous resolution of the pneumothorax is low 5. The recurrence rate of primary spontaneous pneumothorax is 40% 6. Would the cardiologist not put a stent in the coronary arteries if the risk of myocardial infarction was "only 40%"? Therefore, we think that medical thoracoscopy with talc pleurodesis or video-assisted thoracic surgery (VATS) might already be performed in the first episode of pneumothorax. We agree with V. Steger and co-workers that the use of talc pleuorodesis in the young population may make potential surgery for lung cancer more difficult. However, we think that smoking cessation would be the important approach to avoid future development of cancer in the young population.

VATS, under combined general anaesthesia and epidural anaesthesia with double lumen intubation to perform abrasion pleurodesis and stapling of visualised blebs, has been recommended as the first-line approach for the management of recurrent spontaneous pneumothorax with recurrence rates of 3% 7. The patients in our study also had a similar outcome but with a simple, fast and cheaper procedure without the need for general anaesthesia. Furthermore, the results of our study suggest that stapling or electrocoagulation of blebs does not influence the outcome of talc pleurodesis and supports the approach that talc pleurodesis is sufficient for the management of recurrent or persistent primary spontaneous pneumothorax. A recent review article 8 has also concluded that systematic treatment of emphysema like changes with blebectomy or bullectomy is not indicated and that it is the treatment of the pleura (i.e. pleurodesis), and not that of the lung, which should be considered the real cornerstone of recurrence prevention.

Whether medical thoracoscopic talc pleurodesis or video-assisted thoracic surgery is applied depends mainly on the availability of pulmonologists with experience in invasive procedures.

REFERENCES

1. Györik S, Erni S, Studler U, Hodek-Wuerz R, Tamm M, Chhajed PN. Long-term follow-up of thoracoscopic talc pleurodesis for primary spontaneous pneumothorax. Eur Respir J 2007;29:757–760.[Abstract/Free Full Text]
2. Tschopp JM, Brutsche M, Frey JG. Treatment of complicated spontaneous pneumothorax by simple talc pleurodesis under thoracoscopy and local anaesthesia. Thorax 1997;52:329–332.[Abstract]
3. Vanderschueren RG. [Pleural talcage in patients with spontaneous pneumothorax (author's transl.).]. Poumon Coeur 1981;37:273–276.[Medline] [Order article via Infotrieve]
4. Lange P, Mortensen J, Groth S. Lung function 22–35 years after treatment of idiopathic spontaneous pneumothorax with talc poudrage or simple drainage. Thorax 1988;43:559–561.[Abstract/Free Full Text]
5. Schoenenberger RA, Haefeli WE, Weiss P, Ritz R. Evaluation of conventional chest tube therapy for iatrogenic pneumothorax. Chest 1993;104:1770–1772.[Web of Science][Medline] [Order article via Infotrieve]
6. Abolnik IZ, Lossos IS, Gillis D, Breuer R. Primary spontaneous pneumothorax in men. Am J Med Sci 1993;305:297–303.[Web of Science][Medline] [Order article via Infotrieve]
7. Ben-Nun A, Soudack M, Best LA. Video-assisted thoracoscopic surgery for recurrent spontaneous pneumothorax: the long-term benefit. World J Surg 2006;30:285–290.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
8. Noppen M. Management of primary spontaneous pneumothorax. Curr Opin Pulm Med 2003;9:272–275.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]

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