Abstract
Primary spontaneous pneumothorax is a pathology mainly affecting healthy young patients. Clinical guidelines do not specify the type of pleurodesis that should be conducted, due to the lack of comparative studies on the different techniques. The aim of this study was to compare talc poudrage and pleural abrasion in the treatment of spontaneous pneumothorax. A retrospective comparative study was performed, including 787 patients with primary spontaneous pneumothorax. The 787 patients were classified into two groups: Group A (pleural abrasion) n = 399 and Group B (talc pleurodesis) n = 388. The variables studied were recurrence, surgical time, morbidity and in-hospital length of stay. Statistical analysis was done by an unpaired t-test and Fisher's exact test (SSPS 18.0). Statistically significant differences were observed in the variables: surgical time (A: 46 ± 12.3; B: 37 ± 11.8 min; P < 0.001); length of stay (A: 4.7 ± 2.5; B: 4.3 ± 1.8 days; P = 0.01); apical air camera (A: 25; B: 4; P < 0.001); pleural effusion (A: 6; B: 0; P = 0.05). Talc poudrage shows shorter surgical times and length of stay, and lower re-intervention rates. Morbidity is lower in patients with talc poudrage. Statistically significant differences were not observed in recurrence, persistent air leaks, atelectasis and haemothorax.
Keywords: Pneumothorax, Pleurodesis, Talc, Video-assisted thoracoscopy
INTRODUCTION
According to the latest clinical guidelines published by the British Thoracic Society [1] and the American College of Chest Physicians [2], the recommended surgical treatment of spontaneous pneumothorax is videothoracoscopy, with bullectomy or stapling of blebs and subsequent pleurodesis.
There is some controversy with regards to the type of pleurodesis to be performed in patients with spontaneous pneumothorax. Talc poudrage is the treatment of choice for recurrent pleural effusion in oncological patients or in spontaneous pneumothorax in elderly patients. However, its use in young patients is controversial due to the immediate post-surgical side effects (severe hypoxaemia, respiratory distress syndrome or pneumonitis), although several studies point out that these effects seem more related to the size of talc particles or the average doses [3], and show that doses <3 g and particles >6 μm minimize the appearance of acute side effects [4]. Regarding the long-term effects of talc poudrage related to cancerous effects and restriction of respiratory function, an increase in the incidence of pleural or lung cancer is not observed in comparison with the general population as the preparations are regulated by international drug agencies and are free of amianthus, asbestos and other impurities [5]. Other undesirable effects related to the use of talc are histopathological, which simulate primary malignant neoplasias or metastases.
According to several studies such as those published by Hunt et al. [5] or Cardillo et al. [6], the use of talc poudrage in patients, both young and adult, with primary spontaneous pneumothorax is emerging as an effective and safe technique without remarkable short- or long-term side effects and a relapse rate of <2%. This technique is even performed by thoracoscopy and by placing an endothoracic drain through an entrance port under local anaesthesia and sedation, obtaining excellent results [7].
The aim of this study was to analyse the differences between both types of pleurodesis in patients with primary spontaneous pneumothorax, comparing the results obtained by pleural abrasion and by talc poudrage.
MATERIAL AND METHODS
From July 1992 to December 2010, 787 patients were treated in our department for primary spontaneous pneumothorax and were retrospectively identified with our database, which was built up using Access 2002 (Microsoft Corporation, Redmond, WA, USA). Videothoracoscopy was conducted on all the patients, performing bullectomy and pleurodesis, always under general anaesthesia, and selective bronchial intubation maintaining the collapse in the affected lung by placing the patient in the lateral decubitus position, contralateral to the affected lung, using two 12-mm entrances (seventh intercostal space in the median axillary line and third intercostal space in the anterior axillary line) and one 5-mm entrance (fifth intercostal space in the posterior axillary line). The optic employed was a Karl-Storz®, 10 mm and 0°. For the bullectomy, we used a 3.5-mm endostapler Endo-GIA 45 (Autosuture®, Covidien®, New Haven, CT, USA).
Pleurodesis was performed by means of two techniques: mechanical pleural abrasion and talc poudrage. Abrasion was conducted using a sterile sponge, adapted to the entrance ports to irritate the parietal pleura by friction until punctiform haemorrhage were observed. Talc poudrage was performed by insufflating 2–3 g of sterile asbestos-free talc STERITALC® (Novatech, La Ciotat, France) in the pleural cavity through a catheter introduced by the anterior upper and the posterior ports, avoiding direct application on the hilum of the lung. A Pleurocath® 8F (Plastimed Division, Prodimed®, Le Plessis Bouchard, France) pleural drain was left in all patients in the anterior upper position and a Blake 24Fr (Biovac™, Biometrix®, Breda, The Netherlands) drain was left in a posteroinferior position, connected to a Pleur-Evac (Teleflex Medical Ltd®, UK) drainage system. The first catheter was withdrawn 24 h after surgery and the second 48–72 h later, if air leaks had not been observed, and complete lung re-expansion was observed by radiological controls [Group A = pleural abrasion (Table 1) including 399 patients and Group B = talc poudrage with sterile talc including 388 patients (Table 2)].
Table 1:
Group A characteristics: pleural abrasion
| Age | 25.2 years |
| Gender | Women = 8, men = 391 (n = 399) |
| Location | Right = 176, left = 195, bilateral = 28 |
| Smoking exposure | 214 patients (53.6%) |
| BMI | 21.85 kg/m2 |
| Co-morbidity (asthma, emphysema, chronic bronchitis) | 21 patients (5.2%) |
Table 2:
Group B characteristics: talc poudrage
| Age | 29.4 years |
| Gender | Women = 4, men = 384 (n = 388) |
| Location | Right = 194, left = 184, bilateral = 5 |
| Smoking exposure | 233 patients (60%) |
| BMI | 24.13 kg/m2 |
| Co-morbidity (asthma, emphysema, chronic bronchitis) | 26 patients (6.7%) |
There was a constant distribution of talc/abrasion procedures during the 18 years covered in the study, as shown in Fig. 1.
Figure 1:
Distribution of talc/abrasion procedures between 1992 and 2010.
A comparative study was conducted between both groups, using the SPSS 18.0 (SPSS, Inc., Chicago, IL, USA) for the statistical analysis comparing variables such as surgical time and postoperative in-hospital length of stay with unpaired t-test. Other variables, such as recurrence rate and postoperative complications including persistent air leak (more than 7 days), haemorrhage (blood loss >1500 ml in 24 h), apical air camera, pleural effusion, atelectasis, empyema, respiratory distress syndrome and mortality, were studied applying Fisher's exact tests.
RESULTS
Postoperative follow-up of these patients was always conducted by thoracic surgeons, observing the following differences.
The mean surgical time in Group A (pleural abrasion pleurodesis) was 46 ± 12.3 vs. 37 ± 11.8 min in Group B (talc poudrage), observing significant differences between them, favouring Group B (P = 0.001).
In Group A, the total number of postoperative complications was 46 (11.5%), reported as follows: 13 cases of persistent air leak (3.3%), of which 5 required videothoracoscopy; 25 cases of apical air cameras (6.3%), which resolved after respiratory physiotherapy with spirometry in a maximum of 7 days in all cases, except for one that required a new pleural drainage-type Pleurocath®, withdrawn 2 days later; haemorrhage in one case (0.25%); pleural effusion in six cases (1.25%), drained by evacuation thoracentesis and withdrawal of all catheters; and right Horner's syndrome in one case (0.25%), due to excessive pleural abrasion near the stellate ganglion, which persisted. In this group, 11 cases of recurrence of pneumothorax (2.8%) were reported, with re-intervention in 17 patients (4.3%), 11 of them due to recurrence of pneumothorax, 5 due to persistent air leak and 1 due to haemothorax after bleeding of the intercostal vessels.
In Group B (sterile talc poudrage), 14 postoperative complications were reported (3.56%) as follows: 8 cases of persistent air leak (2.01%) for more than 7 days, 4 cases of apical air camera (1.01%), 1 case of laminar atelectasis, all cases resolving with respiratory physiotherapy by incentive spirometry. One case of haemothorax was reported (0.25%) whose origin in the posterior entrance port under the apex of the scapula was confirmed by exploratory thoracoscopy. In this group, four cases of recurrence were reported (1.03%). In all these cases, re-intervention was necessary, as it was in the 2 cases of persistent air leak and 1 case of haemothorax resolved by videothoracoscopy.
The in-hospital length of stay was very similar in all groups, though lower in Group B with an average 4.3 ± 1.8 vs. 4.7 ± 2.5 days in Group A (P = 0.01).
In a comparative statistical analysis, morbidity data obtained on both techniques were as shown in Table 3, containing the recurrence of pneumothorax, with 11 cases in Group A and 4 in Group B (P = 0.116).
Table 3:
Postoperative complications and recurrences
| Group A: abrasion | Group B: talc poudrage | P-value | |
|---|---|---|---|
| Apical air camera | 25 | 4 | <0.001 |
| Persistent air leaks | 13 | 8 | 0.378 |
| Pleural effusion | 6 | 0 | <0.05 |
| Haemothorax | 1 | 1 | 1 |
| Atelectasis | 0 | 1 | 0.493 |
| Horner's syndrome | 1 | 0 | 0.493 |
| Recurrence | 11 | 4 | 0.116 |
Thus, statistically significant differences were observed with better results for talc poudrage regarding apical air camera and pleural effusions and in the total number of cases of persistent air leaks.
Acute respiratory insufficiency after surgery was not reported in any case, nor was there any case of mortality. At present, lung or pleural malignant tumours have not been reported in the population studied.
The long-term outcome was fine in both groups, without chronic pleuritic pain, recurrent fever or mild respiratory discomfort.
Regarding re-intervention, talc poudrage also showed better results (Group A: 17 vs. Group B: 7), without statistically significant results (P = 0.06).
DISCUSSION
The estimated incidence of this pathology is 7.4 cases per 100 000 inhabitants in men and 1.2 cases per 100 000 inhabitants in women [8]. The relapse rate in patients with conventional treatment with endothoracic drainage is 30% (16–52%) and progressively increases after a second or third episode. Surgical treatment is clearly defined in different clinical guidelines, describing VATS bullectomy as the most indicated technique due to its well-known advantages in comparison with conventional surgery (postoperative pain, in-hospital length of stay and so on). An adequate subsequent pleurodesis is necessary in order to minimize the possible relapses in these patients [1, 2, 8]. This point is currently being discussed, including the type of pleurodesis and the type of patients as, according to different studies, talc poudrage has become the most employed technique for pleurodesis [5].
Our study has an important limitation; potential patient selection biases mean that it could be eliminating matching cases according to propensity scores.
The results obtained in the abrasion group regarding recurrence rates, which is the most important complication in these patients and requiring re-intervention on some occasions, are similar across different series. This also occurs in patients undergoing talc poudrage, although recurrence rates were lower in these in comparison with the pleural abrasion group [9–13] (Table 4).
Table 4:
Recurrence rates and postoperative complications in studies on primary spontaneous pneumothorax treatment with VATS
| Study | Year | N | % of recurrence | Air leak >5 days | Apical air camera | Pleural effusion | Pleurodesis |
|---|---|---|---|---|---|---|---|
| Current study: abrasion | 2011 | 399 | 2.76 | 13 (3.3) | 25 (6.3) | 6 (1.5) | Abrasion |
| Gomez et al. [10] | 2005 | 147 | 5.1 | 10 (7.2) | 4 (2.9) | 1 (0.7) | Abrasion |
| Galbis et al. [9] | 2003 | 107 | <10 | Abrasion | |||
| Gossot et al. [11] | 2003 | 111 | 3.6 | Abrasion | |||
| Casadio et al. [12] | 2001 | 137 | 3.6 | Abrasion | |||
| Current study: talc poudrage | 2011 | 388 | 1.03 | 8 (2.1) | 4 (1.0) | Talc | |
| Marmol et al. [13] | 2011 | 130 | 3 | 5 (4.7) | 2 (1.8) | Talc | |
| Cardillo et al. [6] | 2006 | 805 | 1.73 | Talc |
Incidence rates of morbidity are similar in the abrasion and talc poudrage series, as observed with the recurrence rates, although lower in patients undergoing talc poudrage (3.6 vs. 11.5% in the abrasion group). Moreover, incidence rates of air leaks, apical air camera and pleural effusion are also lower in this group, reporting persistent air leak as the most frequent complication in the different series [10, 13].
In this study, acute respiratory distress syndrome (ARDS) has not been reported in any case after intra-pleural talc instillation, nor have there been any cases of severe hypoxaemia or pneumonitis.
Most studies describing ARDS cases or pneumonitis after talc poudrage are from North America or the UK [3], where commercial talc preparations are not standardized, doses are elevated (up to 10 g) and the main pathology treated with talc poudrage was malignant pleural effusion, with high rates of comorbidity.
Different hypotheses focus on the size of the particles as well as the employed doses. In a multicentre prospective study conducted by Bridevaux et al. [4] including 418 patients diagnosed with spontaneous pneumothorax, neither ARDS nor pneumonitis cases were reported using low doses of talc (2 g) and medium-sized particles (31.5 μm), such as the ones employed in our study. Thus, it is probable that secondary complications are directly related to the employed doses and the characteristics of the preparation.
In our study, none of the patients undergoing talc poudrage or pleural abrasion has presented with malignant pleural or lung disease, despite some studies relating the development of malignant disease following the use of talc poudrage. In recent years, a direct relationship between talc poudrage and the further development of pleural or lung disease, including lung cancer or malignant pleural mesothelioma, which is mainly due to the use of talc containing impurities such as asbestos [5], has not been reported. An important aspect in patients undergoing talc poudrage is the possibility of false positives in the interpretation of F-18 FDG PET-CT due to a high captation of FDG in the acute and chronic phases of pleural inflammation, leading to pleural symphysis or the appearance of pleural pseudo-tumoral granulomatous (talcoma) or pseudo-sarcomatous reactions, similar to primary malignant tumoral or metastatic lesions with increased metabolic activity as reported by the PET-CT [14]. This mainly occurs in palliative talc poudrage used for malignant pleural effusion in which higher doses are employed.
A recurrent argument for detractors of talc pleurodesis in young patients is the appearance of firm adhesions or even fibrothorax on the pleural symphysis after talc poudrage, hindering re-intervention with thoracoscopy and leading surgeons to perform important thoracotomies with difficult pleural and lung releases. Cardillo et al. [6] and Doddoli et al. [15] later published data on re-interventions by VATS in patients who had previously undergone talc poudrage with recurrence of pneumothorax without complications. Specifically, Doddoli published a series of 39 patients of whom 27 underwent re-intervention by VATS and only 12 by thoracoscopy, mainly due to an inadequate pleurodesis as talc was instilled into the pleural mediastinum.
Cardillo et al. [6] conclude that with adequate doses of talc, pleural and lung adherences are more firm and more vascularized than those formed after pleural abrasion or any other type of pleurodesis.
In conclusion, the results of this study lead us to consider abrasion and talc poudrage as effective and valid techniques for pleurodesis. Moreover, talc poudrage patients present with lower morbidity and less surgical time, although significant differences have not been observed between both techniques with regard to the recurrence of pneumothorax.
Conflict of interest: none declared.
APPENDIX. CONFERENCE DISCUSSION
Dr L. Molins (Barcelona, Spain): For me the conclusion is that we have similar results. I would apply the less aggressive treatment. For me it is pleural abrasion, of course, because I really don't like to use talc in young people and also I think that the problem in those patients is what might happen in the future. My question is whether you also performed resection of the bullae?
Dr Congregado: We did it when needed, we always looked for bullae, and performed resection of any bullae we saw. But the answer, the real answer of that question is, which one is more aggressive? When I was in my training period, talc poudrage for young patients was forbidden, or almost forbidden, because my master and my professor taught me that. But over the years and after studies like this one, I am changing my mind. I supposed that I would find more recurrences in the pleural abrasion group, but I didn't find that. I found that pleural abrasion had more complications. So maybe this one is more aggressive than talc poudrage. There are people doing it now, and we know that we can perform interventions on people with previous talc poudrage without problems.
Dr A. Toker (Istanbul, Turkey): Do you resect even if there is no bulla?
Dr Congregado: No, if there is no bulla, no.
Dr Toker: If there is no lesion, you don't make any resection?
Dr Congregado: No.
Dr T. Rice (Cleveland, OH): This is a retrospective study. So how were the patients selected to have a talc pleurodesis or not?
Dr Congregado: I understand what you say. In the beginning, in the first years, 1992, we did pleural abrasion in all patients, and in the later years it depended on the surgeon. They are not all the same surgeons. So I just made a retrospective study of two groups, one consisting of patients undergoing pleural abrasion and the other one of patients having talc poudrage.
Dr Rice: But it may be the bias of the surgeon that produces the reported results there.
Dr Congregado: Maybe.
Dr Rice: You can match patients in each group and perform the analysis on patients and see if there is similarity.
Dr Congregado: I could do it.
Dr Rice: Right now your study can be interpreted because of the potential bias and you can't make these conclusions. So I would do a matched analysis. If you do multiple tests on multiple variables, eventually you will find something that is statistically significant by chance. So your present analysis has to be a little bit more sophisticated, and I suggest you match your patients, and it will be a much more valuable study.
Dr Congregado: Thank you for your comment and for your suggestion.
Dr G. Cardillo (Rome, Italy): I have two comments. The first is regarding talc in young people. There is no data against the use of talc poudrage in young people, absolutely no data from the literature. So if somebody says that it can be dangerous, it is absolutely a wrong message.
The second comment is regarding the bulla. I agree with you that if there is a bulla, we can cut. But the data from the literature says that there is no data following cutting of the bulla in spontaneous pneumothorax, because we are not sure that if you cut the bulla, you avoid the risk of spontaneous pneumothorax. So the message is, even concerning the bulla, there is no clear data that following the resection of the bulla, whether it stays a bulla. These are my two comments. So I agree with you with the study, because it is nice and it compares talc poudrage and pleural abrasion, but be careful about recommending to avoid talc poudrage in young, healthy people.
Dr I. Bravio (Lisbon, Portugal): I have one basic question that I would also like to put to Dr. Chapelier and to Dr. Toker. I learned that the gold standard used to be we take up the apex whether there is a bleb, whether there is a bulla, apical pleurectomy, and then pleural abrasion of the remaining pleura. What do you do when you have a recurrence in your patients? I mean, sometimes you have a recurrence when you do the standard procedure. What is your management after, what is the second surgery that you do?
Dr Congregado: Right now in cases like that I do talc poudrage. And, of course, I look for any missed bullae.
Dr Bravio: Now I tie them right away most of the time.
Dr Toker: I am one of those who are against talc, and I prefer to employ pleurectomy with those patients instead of pleural abrasion. So I have no experience of recurrence in those patients, and none of them needed chest drainage. I know it may be very difficult for late intervention, but it seems to be the safest way to prevent recurrence. On the other hand, my question to the talc guys is, do you have a particular size for the talc poudrage? I mean particle size.
Dr Congregado: We use Steritalc, but I don't have all this information in this study. But we use a talc with not very small particles. For a long period we used talc that was made in our hospital, but now I don't know the size of the particles. It has been a long period, 1992 until now. So it is not always the same talc. Maybe this is another limitation of this study.
Dr Toker: Because some different sizes could produce more complications, I guess.
Dr Congregado: Yes, I know. I read about that.
Dr A. Chapelier (Suresnes, France): I would like to make a comment and ask you a question. The comment is that if we start poudrage, you have no pathology. I mean, in some cases you have lymphangioleiomyomatosis, and I think it is a good thing to have a specimen, even for these patients with spontaneous pneumothorax.
And I am a strong defender of pleural abrasion, only abrasion, because, as Albert Camus said, surgeons are like prophets: they do and act regarding the future. So if some of these patients, only the rare patient, have a lung transplantation in the future, it is much better to have an abrasion than a pleurectomy. It could be a very difficult procedure. And the question is, it is well known that talc poudrage can give a kind of pseudo-inflammatory tumour or sarcoma. Did you observe such cases in your experience?
Dr Congregado: Nothing, never. But I know your feeling when somebody is talking about talc poudrage in young people. I know that, because at the beginning I felt the same, because of too many years hearing the same thing. But this is the reason there is this controversy now, a big controversy. I think young surgeons are coming to use it, and we are not finding any difference. Maybe in the future we will see what is going on with all these young people with talc poudrage. But how many people have found that they need to operate on that one person with talc poudrage for transplantation? I think no one now, or a small number. Maybe in the future we will know.
Dr H. Eid (Dubai, UAE): I have already used this technique sometime back in my department, and I didn't have a problem. But when I use it, I am concerned in some patients, because in the literature talc poudrage in this way can, in some cases, cause a sort of ARDS. So if it happens in one patient, you will lose this patient, especially if you use in a dose more than 60 grams. Talc can cause ARDS in patients with pleural effusion or a pneumothorax. So this is one of the rare but serious complications of using talc for pleurodesis.
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