Talc pleurodesis by flexi-rigid thoracoscope under local anaesthesia: visual talc slurry?

We read with great interest the article by Ishida and colleagues [1] reporting a novel approach for talc pleurodesis by dedicated catheter through flexi-rigid thoracoscope. In the literature, talc is believed to be the safest, cheapest and most effective agent for promoting pleural symphysis [2] and, even as reported by the authors themselves, talc poudrage (TP) is the gold standard technique for efficient pleurodesis. Regarding single-port technique, Ishida et al. evidenced a new single-port method in order to insufflate talc into the pleural cavity by using a flexi-rigid thoracoscope in local anaesthesia. Concerning the operative management, the authors did not show any data about pleural adhesions or chambered spaces during the surgical procedures: when these conditions occur, the efficacy of pleurodesis is poorer due to failure of lung re-expansion.

According to our experience on 141 single access video-assisted thoracoscopy procedures, VATS allows to remove most of the false membranes and debris and to wash the cavity under direct visual control. Moreover, unlike the authors data, double lumen endobronchial tube permits lung exclusion in order to offer adequate pleural space visualization and easier management in biopsy, pleural debridement and talc insufflation. In this article, the author did not report any information about patient position, kind of access and anaesthetic technique. In our opinion, this novel approach could be considered as a talc slurry 'under visual control'. It is well-known that, when compared with talc slurry (TS), thoracoscopic talc insufflation is associated with a reduction in recurrence and with a major successful rate [3]. As reported in a prospective not randomized trial comparing TS vs. TP by Stefani et al., chest pain was more common in the TS group and, in five patients initially selected for TS, severe chest pain with acute respiratory distress developed during, or shortly after talc instillation [4]. Anyway, further studies are mandatory to validate the approach proposed by the authors themselves.

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