Recurrence rates of video-assisted thoracoscopic versus open surgery in the prevention of recurrent pneumothoraces: a systematic review of randomised and non-randomised trials

Summary

Background

Evidence supporting similar recurrence rates between video-assisted and open surgery for the treatment of recurrent pneumothorax is questionable, because the number of randomised trials is sparse and they are underpowered to detect any meaningful difference. Our aim was to do a systematic review of randomised and non-randomised studies to compare recurrence rates between the two forms of surgical access.

Methods

We did a systematic literature search for studies on pneumothorax surgery in Medline, Embase, Cochrane Library, trial registers on the internet, and conference abstracts, and identified 29 studies (four randomised and 25 non-randomised) eligible for inclusion. Meta-analysis was done by combining the results of reported recurrence rates in patients undergoing video-assisted thoracoscopic surgery compared with those having open surgery. Both fixed and random effects models were applied to the results pooled for analysis.

Results

In studies that did the same pleurodesis through two different forms of access, the relative risk (RR) of recurrences in patients undergoing video-assisted surgery compared with open surgery was similar between non-randomised and randomised studies (RR 4·880 [95% CI 2·670–8.922] vs 3·951 [0·858–18·193]), yielding an overall RR of 4·731 (2·699–8·291; p<0·0001). There was no evidence to suggest heterogeneity of trial results (p=0·88). The high RR of recurrence for video-assisted surgery remained robust to a random effects model (4·051 [1·996–7·465]; p<0·0001), by including all comparative studies (3·991 [2·584–6·164]; p<0·0001), with only high-quality studies used (4·016 [1·8468·736]; p<0·0001), and on a simulation biased in favour of video-assisted surgery when there were no events in either group (3·559 [2·165–5·852]; p<0·0001).

Interpretation

Both randomised and non-randomised trials are consistent in recurrence of pneumothoraces and show a four-fold increase when a similar pleurodesis procedure is done with a video-assisted approach compared with an open approach.

Introduction

Surgery to prevent recurrent pneumothorax (pleurodesis) is one of the most common thoracic surgical procedures undertaken for benign pleural disease. From 2002 to 2005, centres participating in the Thoracic Surgical Register of the Society of Cardiothoracic Surgeons of Great Britain and Ireland reported that 3183 procedures were done with video-assisted thoracoscopic (minimal access) surgery and 1218 procedures with thoracotomy.¹ The three-fold higher preference for a minimal access approach might be explained in part by perceptions of comparable recurrence rates with less postoperative pain and shorter hospital stay than with open surgery.² The evidence to support such claims is questionable, since the number of randomised trials is sparse and individual trials were underpowered to detect any meaningful difference in recurrence rates between the two forms of surgical access. Moreover, the focus of most studies has been on subjective outcomes that are difficult to assess in a blinded fashion (because of the nature of surgical intervention), such as postoperative pain and hospital stay (which itself is a measure that is not entirely without bias).

Whether the prevention of recurrent pneumothoraces can be achieved with similar efficacy with use of a video-assisted thoracoscopic approach needs to be established before focusing on secondary outcomes. Our aim was to do a systematic review and meta-analysis of randomised and non-randomised trials to determine if there were any differences in recurrence rates in patients undergoing either video-assisted thoracoscopic or open surgery for pneumothorax.