Is video-assisted thoracoscopic surgery talc pleurodesis superior to talc pleurodesis via tube thoracostomy in patients with secondary spontaneous pneumothorax?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was [in patients with secondary spontaneous pneumothorax (SSP)] is [video-assisted thoracoscopic surgery talc pleurodesis] superior to [talc pleurodesis through tube thoracostomy] in terms of [absence of recurrence and procedure morbidity]? Seventy-three papers were found using the reported search. In looking through our search strategy, we selected studies comparing both procedures and studies performing either procedures and stating their outcome, morbidity mortality and rate of recurrence. Hence, six studies and one society guideline represented the best evidence to answer the clinical question. The authors, journal, date, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Only one study compared both techniques and showed a higher length of hospital stay (14.2 vs 10.6 days; P = 0.033), higher rate of recurrence (30 vs 4.5%; P = 0.016) and higher mortality (5 vs 0%; P = 0.280) with tube thoracostomy talc pleurodesis in comparison with video-assisted thoracoscopic surgery (VATS) talc pleurodesis. Two studies looked at talc pleurodesis via tube thoracostomy (TT) alone for patients with secondary spontaneous pneumothorax (SSP). Talc pleurodesis was associated with an immediate success rate of 78.1 and 78.6%, with a short-term recurrence rate of 21.9 and 21.4%. No mortality was recorded in any study, but 1 patient (1.6%) in one study suffered from respiratory distress. No long follow-up periods were available in both studies; hence, there is no recording of long-term recurrence. Three studies looked at VATS talc pleurodesis alone in SSP patients. The procedure was associated with higher immediate success rates (90-100%) than TT pleurodesis alone with lower recurrence rates (0-10%). Average hospital stay was in the range of 3-4.7 days. Follow-up periods were 18, 22.7 and 24 months with recurrence rate ranging from 0 to 15%. No study was associated with major postoperative morbidity or in-hospital mortality. In conclusion, while there is only one study directly comparing both VATS and tube thoracostomy talc pleurodesis, the best evidence suggests that VATS talc pleurodesis for patients with secondary spontaneous pneumothorax should be considered the treatment of choice as it is associated with a higher immediate success rate, lower recurrence rate and a lower mortality than talc pleurodesis via tube thoracostomy.