Therapeutic thoracoscopy under local anesthesia.

We read with great interest the report by Nezu et al on thoracoscopic bullectomy performed under local anesthesia for the treatment of spontaneous pneumothorax (January 1997).x The authors selected patients with no pleural adhesions (by air insufflation and then x-ray), and they tried to identify their bullae preoperatively by using CT scans. They compared their results with those of a historical group in which the same procedure was performed under general anesthesia; they then concluded that the approach using local anesthesia is safe and is associated with a shorter hospital stay. We would like to raise four points. First, in our experience, it is relatively unusual for recurrent primary spontaneous pneumo¬ thorax not to have any adhesions, as the natural history of a ruptured bulla is eventual adhesion to the chest wall. Therefore, if this selection criteria is strictly followed, it seems that the described procedure will be applicable only to a relatively small group of patients.