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Correspondence

Reply

Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Departments of Surgery and Traumatology, No. 7, Chung-Shan South Rd, Taipei, 100 Taiwan

(Email: ntuhycl{at}gmail.com).

To the Editor:

We 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. In our hospital, we prefer simple aspiration because it is as effective as CTD with reduced morbidity, hospital stay, and the need for hospitalization [3]. Using VATS is usually reserved for patients with recurrence or persistent air leakage.

The definition of "persistent" air leakage after CTD is arguable, because almost all primary pneumothoraxes resolve spontaneously within 14 days. To prevent prolonged hospitalization, the American College of Chest Physicians (ACCP) recommends continued observation for 5 days before encouraging the patient to accept a surgical intervention [4]. Several authors, including us, have recommended operative intervention as early as 3 days for a persistent air leak [5]. The definition and management of persistent air leakage after simple aspiration is more contentious. In the guidelines published by the British Thoracic Society, CTD is recommended if repeat aspiration is unsuccessful, without providing any evidence [6]. If we accept that simple aspiration is equally effective as CTD in managing primary spontaneous pneumothorax, why should we choose CTD as the salvage procedure after unsuccessful aspiration? We hypothesize that patients with unsuccessful aspiration represent highly selected individuals with a higher failure rate of treatment even if a chest tube has been placed, and a more effective procedure such as VATS should be considered.

In our CTD patients, we perform VATS if air leaks are greater than 72 hours. We agree that VATS costs more medical expenditure when compared with CTD alone. However, if these young, active patients can go back to work or school earlier without fear of prolonged air leakage and recurrence, maybe more social resources can be saved. A prospective, randomized study is recommended to answer the controversy regarding the optimal treatment for patients with unsuccessful simple aspiration.

	References

Top References

 

1. Elsayed HH. Should thoracoscopic surgery be the standard management for patients with primary pneumothorax?(letter) Ann Thorac Surg 2009;87:991.[Free Full Text]
2. Chen JS, Hsu HH, Tsai KT, Yuan A, Chen WJ, Lee YC. Salvage for unsuccessful aspiration of primary pneumothorax: thoracoscopic surgery or chest tube drainage? Ann Thorac Surg 2008;85:1908-1913.[Abstract/Free Full Text]
3. Noppen M, Alexander P, Driesen P, Slabbynck H, Verstraeten A. Manual aspiration versus chest tube drainage in first episodes of primary spontaneous pneumothorax: a multicenter, prospective, randomized pilot study Am J Respir Crit Care Med 2002;165:1240-1244.[Abstract/Free Full Text]
4. Baumann MH, Strange C, Heffner JE, et al. AACP Pneumothorax Consensus Group Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement Chest 2001;119:590-602.[Abstract/Free Full Text]
5. Granke K, Fischer CR, Gago O, Morris JD, Prager RL. The efficacy and timing of operative intervention for spontaneous pneumothorax Ann Thorac Surg 1986;42:540-542.[Abstract/Free Full Text]
6. Henry M, Arnold T, Harvey J, Pleural Diseases GroupStandards of Care CommitteeBritish Thoracic Society BTS guidelines for the management of spontaneous pneumothorax Thorax 2003;58(suppl 2):39-52.

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