The best treatment for the first episode of primary spontaneous pneumothorax: an unanswered question.

I read with great interest the study by TSCHOPP et al. [1]. They compared in a multicentre randomised study two groups of patients with primary spontaneous pneumothorax (PSP), in order to study the recurrence rate, the side-effects (mainly the pain) and the cost of two treatment modalities, thoracoscopic talcage (TT) or pleural drainage (PD). They found that, after 5 yrs of follow-up, 34% of PSP patients treated with PD relapsed, versus 5% in the TT group, and that TT is a safe, cost-effective treatment with less morbidity provided there is an efficient control of pain by opioids. I expected to find an answer to a recurrent and essential question in this manuscript: "do we have to propose TT or simple PD for the first episode of PSP if aspiration has failed?" Unfortunately, this was not the case. Indeed, the authors decided to include all the patients with PSP, whether they presented with a first or a recurrent episode of PSP. As shown in table 2, only 23 and 36% of the patients treated with TT and PD respectively, had a first episode of PSP. We all know, as the authors quoted in their introduction, that there is a "general consensus that some treatment is mandatory with second or recurrent SP". In other words, a TT is advised from the first recurrence. Scarce scientific data, but above all, clinical experience suggests that after a first recurrence of PSP, the incidence of subsequent recurrences increases progressively over time, up to 62% for a second and 83% for a third recurrence [2]. To show that TT as compared to PD is a cost-effective treatment for a majority of patients with recurrent PSP, brings no major information. A subanalysis of the "true" patients (with first episode of PSP) would have given more power to this study. Another study should be reproduced eventually using patients with a first episode of PSP. It should offer relevant answers in our current practice, and will complete the data of a nonrandomised and nonprospective study performed by SCHRAMEL et al. [3] that was published in the European Respiratory Journal in 1996. These authors also examined the cost-effectiveness of PD versus TT for PSP in two successive periods. TT was not cheaper than PD except if the costs of the waiting times before TT were subtracted. All kinds of PSP were included. One-third of the patients presented with a recurrent …