Surgical vs Non-Surgical Management of Pleural Empyema: A Meta-Analysis

Abstract

Purpose: There is currently no consensus on the optimal treatment regimen for pleural empyema, with surgical decortication attracting interest due to recent advances in video-assisted thoracoscopic surgery (VATS). Some centres advocate early decortication, whilst others continue to prefer a trial of chest tube drainage (CTD) prior to surgical intervention. This meta-analysis sought to assess the evidence regarding non-surgical vs early surgical options. Methodology: Electronic searches were performed using six databases from their inception to July 2015, identifying all relevant randomised controlled trials (RCT) that compared a surgical versus a non-surgical method of pleural empyema management. Results: Eight RCTs with 391 participants were included. Six of these focussed on paediatric population and two on adults, with seven comparing CTD to VATS decortication, whilst one paediatric trial compared CTD to open decortication. The study (n = 30) comparing open decortication to CTD reported no deaths in either arm, but showed a reduction in length of hospital stay (9.5 vs 15.4 p < 0.05), and less procedural complications (p = < 0.05). In the seven studies (n = 361) comparing VATS decortication versus CTD, there were one mortality in each group, and a reduction in length of hospital stay (mean difference -2.52 p < 0.05). There was no statistically significant difference in procedural complications rate. Conclusions: Our findings suggest early surgical management of pleural empyema may reduce length of hospital stay when compared to CTD, without an increased risk of procedural complications. However, these were based on a limited number of studies and sample size. Future RCTs with larger sample sizes are required to validate our findings.