REVIEW ARTICLE

Surgical access rather than method of pleurodesis (pleurectomyor pleural abrasion) influences recurrence rates for pneumothoraxsurgery: systematic review and meta-analysis

Andrea Bille • Allanah Barker • Eleni C. Maratos •

Lyn Edmonds • Eric Lim

Received: 25 November 2011 / Accepted: 31 January 2012 / Published online: 8 May 2012

� The Japanese Association for Thoracic Surgery 2012

Abstract

Aim Surgery for recurrent spontaneous pneumothoraces

is one of the most commonly performed procedures in

thoracic surgery, but few studies have evaluated the effi-

cacy of the surgical treatment options. We aimed to eval-

uate the influence of the type of pleurodesis on recurrence

whilst adjusting for surgical access by systematic review

and meta-regression of randomised and non-randomised

trials.

Methods A systematic literature search undertaken for

studies on pneumothorax surgery in MEDLINE, EMBASE,

Cochrane Library, Internet trial registers and conference

abstracts identified 29 studies (4 randomised and 25 non-

randomised) eligible for inclusion. Meta-regression was

performed adjusting for access to screen for evidence of a

difference in recurrence rates.

Results Access remained the principal determinant of

recurrence rates after surgery. The relative risk of recur-

rence was 4.731 (2.699–8.291; p \ 0.001) using video-

assisted thoracoscopic surgery compared to open access.

After adjusting for access, the relative risk of recurrence of

pleural abrasion compared to pleurectomy was observed to

be 2.851 (95 % CI 0.478–17.021), but this was not statis-

tically (p = 0.220).

Conclusion Surgical access remains the most important

factor that influences outcome after surgery for recurrent

pneumothoraces. Although the relative risk of recurrence

was higher with pleural abrasion compared to pleurectomy,

it was not statistically significant, and more work needs to

be conducted to address this question.

Keywords Spontaneous pneumothorax � Recurrence �Pleurectomy � Pleural abrasion � Complications � Surgical

access

Introduction

Surgery for recurrent spontaneous pneumothoraces is one

of the most commonly performed procedures in thoracic

surgery. With respect to the volume of clinical work, there

are few studies that evaluate the efficacy of the surgical

treatment options.

Previously in the Lancet, we reported an estimated

fourfold higher recurrence rate in studies performing the

same pleurodesis using video-assisted thoracoscopic sur-

gery (VATS) as opposed to open access for the intended

surgery [1]. To further our work, we aimed to evaluate the

influence of the type of pleurodesis (pleurectomy vs.

pleural abrasion) on recurrence whilst adjusting for

A. Bille (&)

Thoracic Surgery Department, Guy’s and St. Thomas’ Hospital,

London SE1 9RT, UK

e-mail: andrea_bille@hotmail.it

A. Barker � E. C. Maratos

Department of Cardiothoracic Surgery, Papworth Hospital,

Cambridge, UK

L. Edmonds

Library and Knowledge Services, Papworth Hospital,

Cambridge, UK

E. Lim

Department of Thoracic Surgery, Royal Brompton Hospital,

London, UK

123

Gen Thorac Cardiovasc Surg (2012) 60:321–325

DOI 10.1007/s11748-012-0080-9

surgical access (VATS vs. open surgery) by systematic

review and meta-regression of randomised and non-ran-

domised trials.

Methods

A systematic literature search was undertaken of Medline

(1950 to Oct 2006), Embase (1974 to Oct 2006) and

Cochrane Library 2006, Issue 4. To maximize the sensi-

tivity of the search strategy and identify all trials com-

paring thoracoscopy and thoracotomy, we used appropriate

free text and thesaurus terms including Pneumothorax,

Thoracoscopy, Thoracotomy and Comparative-Study. No

restrictions were placed on language.

No restrictions were placed on abstracts, conference

proceedings or language. Our exclusion criteria were

studies that were not directly relevant to pneumothorax

surgery, studies that did not include a comparative surgery

group and studies in which recurrence rates could not be

discerned. A given patient population was only used once:

if the same population appeared in other publications, the

article that provided the most complete follow-up data on

recurrence was selected. In all publications, we classified

data on surgical access (e.g. VATS, open surgery) sepa-

rately to the intended surgical procedure (e.g. apical

pleurodesis, pleural abrasion, talc insufflation).

Statistical methods

Meta-analysis was performed by combining the results of

reported recurrence rates in patients undergoing VATS

compared to open surgery. A fixed effect meta-analysis

was performed to pool within-study recurrence rates

between two different forms of access (VATS vs. open

surgery) where the same pleurodesis procedure was per-

formed in both groups and meta-regression was used to

determine the between-study influence of type of pleu-

rodesis (pleurectomy vs. pleural abrasion). Statistical het-

erogeneity of trial results was tested using the v2 test of

homogeneity and also expressed as I2: the percentage of

total variability attributed to the individual trials as a

measure of inconsistency between studies (a value of 25 %

or less is regarded as low) [2]. Statistical analyses were

performed using Stata 9.2 (StataCorp, College Station, TX,

USA).

Fig. 1 Relative risk (RR) of

recurrence of pneumothorax

comparing video-assisted

thoracoscopic to open surgery

for recurrent pneumothoraces in

all studies

322 Gen Thorac Cardiovasc Surg (2012) 60:321–325

123

Results

Our search strategy identified 288 publications, of which

147 were excluded for not being directly related to surgery

exclusively for pneumothorax and 100 excluded for not

having a comparative surgical group leaving 41 studies

suitable for evaluation [3–43]. Six further studies were

excluded, where the recurrence rates could not be discerned

from the manuscript [32–37], 6 trials were excluded for

duplicate reporting [38–43], leaving 29 studies (4 ran-

domized and 25 non-randomized) eligible for overview and

inclusion in the meta-analysis [3–31].

As previously reported [1], the relative risk of recur-

rence comparing two different forms of surgical access

(VATS vs. open surgery) within each study was 4.731

(2.699–8.291; p \ 0.001, Fig. 1), with no evidence to

suggest statistical heterogeneity of trial results (v152 = 8.92,

p = 0.882), with variation in relative risk attributable to

heterogeneity (I2) of 0 %.

Of the 19 studies, 3 used a combination of pleurectomy

and abrasion, and 1 study performed blebectomy alone. Of

15 studies that performed exclusively pleurectomy or

pleural abrasion (9 pleurectomy, 6 pleural abrasion) in both

access arms, meta-regression (adjusting for type of proce-

dure) suggested no statistically significant difference in

recurrence rates between the studies that performed

pleurectomy compared to those that performed pleural

abrasion (p = 0.220); however, the relative risk of recur-

rence of pleural abrasion compared to pleurectomy was

observed to be 2.851 (95 % CI 0.478–17.021).

Discussion

Whilst the role of pleurodesis in the treatment of sponta-

neous pneumothorax is clear, the optimum procedure to be

performed remains undefined. The results of our study

suggest that surgical access rather than procedure is the

principal determinant of recurrence rates.

In general, studies on surgery for pneumothoraces have

been poorly conducted and reported, many studies do not

clearly differentiate between surgical access and procedure

performed. To date, evidence to guide our practice has been

sparse and it has been impossible for surgeons to accurately

evaluate the treatment efficacy of both types of procedures.

To circumvent this problem, we applied meta-regression

to screen for any evidence to suggest a difference in

recurrence rates comparing the two forms of pleurodesis

after adjusting for surgical access. Whilst we found no

evidence to suggest any difference it is important to rec-

ognize that many studies were not originally designed to

compare the different techniques of surgical pleurodesis,

and a number of those did not distinguish between patients

who underwent pleurectomy or pleural abrasion. We had

previously discussed the limitations of meta-analyses that

are conducted on trials with sparse outcomes.

Therefore, we only summarize from the current avail-

able literature rather than provide a definitive answer to our

original question, and this stems from the poor number or

quality of the trials on this topic. Moreover, we cannot

ascertain the surgical expertise of the surgeons taking part

in the clinical studies and, therefore, are unable to assess

the impact of any ‘‘learning curve’’ that may account for

the higher recurrence rates in patients in the VATS treat-

ment arms.

It is important to note that whilst statistical significance

was not achieved, the possibility of a type II error rate is

high, given the small number of studies and events expe-

rienced and, therefore, the estimated relative risk of

recurrence of 2.85 comparing pleural abrasion to pleurec-

tomy cannot be ignored and requires further study.

As talc is an increasingly popular alternative to pleur-

ectomy and pleural abrasion, the need for a randomized

trial to compare the various treatment efficacies becomes

increasingly important. Moreover, the complex interactions

between the anatomic extent of surgery, completeness of

pleurodesis and the form of access can only be adequately

addressed in a randomized trial. One such study published

by Rena et al. [44] reported a 4.6 % recurrence rate after

pleurectomy and 6.2 % recurrence rate after pleural abra-

sion. Although we calculate the estimated risk of recur-

rence comparing abrasion to pleurectomy as 1.3, this did

not achieve statistical significance and the authors con-

cluded no difference in the two forms of surgery. As with

the vast majority of trials on the subject, it is difficult to

draw firm conclusions, as the event rate is low, leading to

wide confidence intervals on the estimation of the treat-

ment effects.

Conclusions

From the available evidence published, surgical access

remains the most important factor that influences outcome

after surgery for recurrent pneumothoraces, with VATS

access resulting in a 4-fold higher rate of recurrence

compared to open access. Although the relative risk of

recurrence was higher with pleural abrasion compared to

pleurectomy, it was not statistically significant, and more

work needs to be conducted to address this question.

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