Lung volume reduction surgery for diffuse emphysema

Leong Ung Tiong; Peter G Gibson; Michael J Hensley; Rebecca Hepworth; Toby J Lasserson; Brian Smith; Huw Richard H R Davies

doi:10.1002/14651858.CD001001.pub2

Reducción quirúrgica del volumen pulmonar para el enfisema difuso

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Referencias adicionales

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Hensley M, Coughlan JL, Davies HR, Gibson P. Lung volume reduction surgery for diffuse emphysema. Cochrane Database of Systematic Reviews 1999, Issue 4. [Art. No.: CD001001. DOI: 10.1002/14651858.CD001001.]

Characteristics of studies

Characteristics of included studies [ordered by study ID]

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Criner 1999

Methods	Prospective, randomised controlled trial. Allows cross‐over of patients from medical to surgical arm after they had completed evaluation after 3 additional months of medical therapy and rehabilitation. Method of randomisation: Not described Allocation concealment: unclear Outcome Assessor blinding: not described. Withdrawal/Dropouts: fully accounted for.
Participants	Screened: 200 Randomised: 37 (LVRS: 19; control: 18) Mean age: 59 Emphysema: diffuse, heterogeneous, bullae less than 5 cm Diagnosis: CT Scan Baseline demographics: FEV1: 29% (SD 8%) predicted PaO2/FlO2: 318 PaCO2: 46.4 DLco: 1.9 (SD 0.7) 6 minute walk: 266 (SD 92) Entry criteria: Non‐smokers (>/= 6 months); symptomatic despite optimised medical therapy; NYHA Class III–IV; evidence of airflow obstruction & hyperinflation by pulmonary function studies (i.e., FEV1 < 30% of predicted, postbronchodilator administration, FRC or TLC> 120% of predicted), hyperinflation documented by chest X‐ray and diffuse bullous emphysema documented by high‐resolution computed tomography (CT) scan, decreased or absent perfusion documented in planned resected lung tissue by quantitative perfusion lung scan Exclusion criteria: Severe & refractory hypoxemia (PaO2/FIO2 ratio < 150); severe hypercapnic respiratory failure requiring mechanical ventilation; presence of significant cardiovascular disease; presence of severe pulmonary hypertension (mean pulmonary artery pressure > 35 mm Hg); severe debilitated state with total body weight < 70% of ideal body weight, presence of significant extrapulmonary end‐organ dysfunction expected to limit survival; psychosocial dysfunction; continued smoking.
Interventions	LVRS via MS & bilateral stapling resection versus usual medical care (including pulmonary rehabilitation). Pulmonary rehabilitation: 8 week prgramme with additional 3 months in patients randomised to control. PR had educational, physical, psychosocial supportive components. All participants had individualised programmes based on exercise test results. Outcomes assessed 8 weeks of outpatient pulmonary rehabilitation, and 3 months after additional pulmonary rehabilitation or LVRS.
Outcomes	Lung function (performed following ATS guidelines); Arterial blood gases; Sickness Impact Profile (SIP); mortality
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Adequate sequence generation?	Unclear risk	Described as randomised; no other information available
Allocation concealment?	Unclear risk	Information not available

Geddes 2000

Methods	Randomised parallel group trial Method of randomisation: Not described. Allocation concealment: Off‐site Outcome Assessor blinding: not described Withdrawal/Dropouts: Fully accounted for.
Participants	Screened: 174 Randomised: 48 (LVRS: 24; control: 24). Median age: 61years Emphysema: No restriction on pattern & distributrion Diagnosis: CT scan Baseline demographics: FEV1 (liters) 0.75 Shuttle‐walking distance (m) 215 SF‐36 score 50 FVC (liters) 2.86 Residual volume (% of predicted) 223 Total lung capacity (% of predicted) 133 PaCO2 (mm Hg) 38 PaO2 (mm Hg) 72 DLco (% of predicted): 37 Entry criteria: CT‐confirmed severe emphysema; <75 years; FEV1 >500ml; CS dose <10mg/d Exclusion criteria: O2 use >18hrs/d;
Interventions	LVRS via median sternotomy or thoracoscopy versus continued medical care. Continued medical care included rehabilitation and optimised drug therapy. Pulmonary rehabilitation: 6 week programme consisting of physical, occupational health, nutritional education components. Participants were telephoned in order to encourage them to adhere with the exercise programme. Outcome assessment took place at three, six and twelve monthly intervals.
Outcomes	Mortality; FEV1; FVC; TLC; RV; shuttle‐walking distance, and quality of life; inspiratory and expiratory mouth pressures; arterial‐blood gas values
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Adequate sequence generation?	Unclear risk	Described as randomised; other information not available
Allocation concealment?	Low risk	Third party

Goldstein 2003

Methods	Randomised controlled trial. Method of randomisation: Random numbers table, block randomisation in groups of four. Allocation concealment: adequate Outcome assessor blinding: described. Withdrawal/Dropouts: Fully accounted for.
Participants	Screened: 328 Randomised: 55 (LVRS: 28, control: 27) Mean age: 65 years Emphysema: heterogenous distribution Diagnosis: CT or V/Q scan Baseline demographics: FEV1: 33% predicted PaO2: 9.4 kPa PaCO2: 5.8 kPa TLC: 38% predicted FVC: 74% predicted RV: 238% predicted Entry criteria: <75 years; FEV1 <40% predicted; TLC >120% predicted; evidence of heterogenous emphysema on CT or V/Q scan Exclusion criteria: asthma; prior lung surgery; pleural disease; contraindications for surgery; inability to attend PR or follow‐up; pulmonary hypertension.
Interventions	LVRS via video‐assisted thoracic surgery (VATS) (or less often by median sternotomy at the discretion of the surgeon) versus ongoing medical treatment including pulmonary rehabilitation. A short course of pulmonary rehabilitation was offered to participants in the surgery group. Pulmonary rehabilitation: Six week programme with supervised physical exercise, educational, and psychosocial components Outcomes assessed at 3, 6, 9, and 12 months after randomisation.
Outcomes	Quality of life (measured by the CRDQ); Six‐minute walking distance, submaximal cycle endurance time; FEV1; FEV1/FVC; RV; FRC; TLC; mortality
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Adequate sequence generation?	Low risk	Random numbers table, block randomisation in groups of four.
Allocation concealment?	Low risk	Third party

Hillerdal 2005

Methods	Randomised controlled trial Method of randomisation: randomised number lists (blocks of four) Allocation concealment: off site, concealed from participants (adequate) Outcome Assessor blinding: not described. Withdrawal Dropouts: fully accounted for.
Participants	Screened: 304 (eligible: 114) Randomised: 106 (LVRS: 53; control: 53) Completed: 83 (LVRS: 42; control: 41) Age: Mean 62 Diagnosis: CT Scan Emphysema: diffuse Major exclusions: asthma or bronchitis; smoking; DLco </=20% predicted age; sequelae of pleurisy/pleural adhesions; long‐term OCS treatment. Baseline: FEV1: 27% predicted FVC 75% predicted 6 minute walk: 218m Comments: 8 had alpha1 antritrypsis deficiency.
Interventions	Bilateral LVRS by median sternotomy (N = 42) or video‐assisted thoracoscopy (N = 3) versus continued physical training. Physical training offered to both treatment groups. Study duration: participants followed up for one year post‐randomisation.
Outcomes	Mortality, lung function, withdrawal, quality of life (SGRQ and SF‐36), exercise capacity (6 minute walk test & shuttle walk test)
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Adequate sequence generation?	Low risk	Randomised number lists (blocks of four)
Allocation concealment?	Low risk	Conducted off site

McKenna 1996

Methods	Randomised Controlled Trial of two interventions Method of Randomisation: Not described. Allocation concealment: not described Outcome Assessor blinding: not blinded. Withdrawal Dropouts: fully accounted for.
Participants	Eligible: 72 Randomised: 72 (Laser 33; Staple 39) Completed: 62 (Laser 26; Staple 36) Age: Mean 67 (SD 7) Diagnosis: CT Scan Emphysema: diffuse, heterogeneous, bullae less than 5 cm Diseases Included: not stated Major exclusions: smoking no prior thoracic surgery, age >75yrs, Co2 retention>55mmHg, severe cardiac disease, cancer within the past 5 years, ventilator dependency, presence of a lung mass, bullae > 5cm. Baseline: FEV1 27% (SD6%) of predicted FVC 58% (SD9%) of predicted Lung Vds DLCO PaO2 PaCO2 6 minute walk Comments: None had alpha1 antritrypsis deficiency, 68% were taking oral corticosteroids, 72% required supplemental oxygen therapy.
Interventions	LASER: Extent: Bilateral/Unilateral ‐ unsure Approach: Thoracoscipic Resection Method: Nd:YAG (neodymium:yttrium‐aluminium‐garnet laser) Non‐surgical: pulmonary rehab post op continued for 2 to 3 weeks after discharge Medications: STAPLING: Extent: Unilateral Approach: Thoracoscipic Resection Method: Stapling with bovine pericardium reinforcement Non‐surgical: pulmonary rehabilitation post operatively continued for 2 to 3 weeks after discharge Medications: Not clear. Other: All patients in both groups were educated and encouraged to join a 'Better Breathers Club'.
Outcomes	Morbidity, Air leaks, Delayed Pneumothorax, FEV1, MOS‐36, Operation time (hrs), Length of Stay, Supplemental Oxygen Therapy, Repiratory Failure.
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Adequate sequence generation?	Unclear risk	Described as randomised; no other information available
Allocation concealment?	Unclear risk	Information not available

Miller 2005

Methods	Randomised parallel group trials reported as one data set. Method of Randomisation: Not described. Allocation concealment: conducted off site at a data coordinating centre Outcome Assessor blinding: described Withdrawal Dropouts: fully accounted for.
Participants	Screened: 738 Randomised: 93 (LVRS: 58; control: 35) Completed: 81 (LVRS: 47; control: 34) Mean age: 64 (SD 7) Diagnosis: CT scan Emphysema: Heterogeneous Diseases Included: not stated Entry criteria: severe emphysema; breathlessness despite optimal medical therapy Major exclusions: Dominant lower lobe emphsema; saccular bronchiectasis; pulmonary nodules >0.7 cm present <2 years showing signs of malignancy Baseline: FEV1: 0.7 L DLCO: 8 mL/min/mm Hg PaO2: 68mm Hg PaCO2: 45mm Hg 6 minute walk: 329m
Interventions	LVRS via median sternotomy versus usual medical care. Optimal care standardised in both treatment groups (including PR, bronchodilators, vaccination, steroids and antibiotics) Pulmonary rehabilitation: 6 week course prior to randomisation (and continued for the duration of the study in both groups) Participants followed up for two years post randomisation.
Outcomes	Morbidity; lung function; quality of life (CRDQ); exercise capacity; withdrawal
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Adequate sequence generation?	Low risk	Described as randomised; information not available
Allocation concealment?	Low risk	Conducted off site at a data coordinating centre

NETT

Methods	Randomised controlled trial Method of randomisation: Computer‐generated random number sequence Allocation concealment: adequate Outcome assessor blinding: not described
Participants	Screened: 3777 Randomised: 1218 (LVRS: 608; control: 610) Mean age: 66.6 Emphysema: heterogenous and homogenous Diagnosis: CT scan Entry criteria: FEV1 </= 45 % predicted (>/= 15 % predicted among participants 70 years of age or older); TLC >/= 100% predicted; RV >/= 150% predicted; partial pressure of resting arterial carbon dioxide 60 mm Hg or less; resting partial pressure of arterial oxygen >/= 45 mm Hg; ability to walk >/= 140 m in six minutes; ability to complete three minutes on bicycle ergometer; abstinence from smoking for six months prior to randomisation. Exclusion criteria: Concurrent medical conditions precluding surgery or that might interupt follow‐up. Baseline: FEV1: 27% 6 minute walk test: 1218 feet TLC: 128% predicted RV: 221% predicted DLco: 28.3% predicted PaO2: 64.3mm Hg PaCO2: 43 mm Hg SGRQ: 53
Interventions	LVRS via VATS or MS versus usual medical care according to ATS recommendations Usual care tailored to each participant in the control group. This included: smoking cessation (for those resuming smoking during course of the study); drug therapies (including CS and inhaled bronchodilators); LTOT; immunisations, and continued pulmonary rehabilitation. Pulmonary rehabilitation: Three phases: pre‐randomisation (6‐10 weeks); post‐randomisation: 8‐9 weeks) and long‐term maintenance (duration of the trial). PR consisted of physical, educational and psychosocial components (including nutritional counselling). Offered to both treatment groups.
Outcomes	Mortality; exercise capacity; quality of life; FEV1; FVC; RV; cost; complications; length of hospital stay
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Adequate sequence generation?	Low risk	Computer‐generated random number sequence
Allocation concealment?	Low risk	Conducted by third party

Stammberger 2000

Methods	Randomised controlled trial. Method of randomisation: not described. Allocation concealment: not clear. Blinding of assessors: not described.
Participants	Screened: not reported Randomised: 74 (65 analysed ‐ buttressed group: 32; non‐buttressed group: 33) Completed: 65 (LVRS: 32; control: 33) Mean age: 60 Emphysema: Homogeneous (N = 12); intermediate heterogeneous (N = 11); heterogeneous (N = 37). Diagnosis: CT scan Entry criteria: radiological evidence of emphysema; breathlessness leading to impaired quality of life; consent; FEV1 < 35% predicted; optimal medical therapy; candidature for lung transplantation Major exclusions: Current smoker; > 75 years; 'vanishing lung' on CT; TLco < 20% predicted; hypercapnia; pulmonary hyoertension; bronchiectasis; chest infection; OCS therapy > 15mg/d Baseline: FEV1: 27% predicted Residual volume: 286 % predicted PaO2: 65mm Hg PaCO2: 41mm Hg Dyspnoea score: 3.4
Interventions	Buttressed versus non‐buttressed stapling device in LVRS procedures. Pulmonary rehabilitation not undertaken as part of study protocol.
Outcomes	Length of hospital stay; FEV1; dyspnoea; PaO2 & PaCO2; complications; mortality
Notes
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Adequate sequence generation?	Unclear risk	Described as randomised; other information not available
Allocation concealment?	Unclear risk	Information not available

CRDQ: Chronic Respiratory Disease Questionnaire; CS: corticosteroid; FEV1: Forced expiratory volume in one second; FVC: Forced expiratory vital capacity; LTOT: Long‐term oxygen therapy; LVRS: Lung volume reduction surgery; MS: Median sternotomy; OCS: oral corticosteroids; RV: Residual volume; SGRQ: St George's Respiratory Questionnaire; SF‐36: Short‐form 36 questionnaire; TLC: Total lung capacity; V/Q scan: Ventilation/perfusion scan; VATS: Video‐assisted thoracic surgery.

Characteristics of excluded studies [ordered by study ID]

Ir a:

estudios incluidos
estudios en curso

Study	Reason for exclusion
Daniel 1996	Case series.
Keenan 1996	Case series.
Kotloff 1996	Case series.
Little 1995	Case series.
Martinez 1997	Prospective case series.
Nickoladze 1992	Case series in patients with bullous emphysema.
O'Brien 1999	Prospective case series.
Pompeo 2000	Includes diffuse bullous emphysema (with heterogeneous distribution).
Sciurba 1996	Prospective case series.
Szekely 1997	Prospective case series with retrospective review of preoperative characteristics.
Tan 2000	Prospective case series (not randomised).
Teschler 1996	Prospective case series.
Wakabayashi 1995	Case series using laser pneumoplasty.

Characteristics of ongoing studies [ordered by study ID]

Ir a:

estudios incluidos
estudios excluidos

Goodnight 2001

Trial name or title
Methods
Participants	People with severe emphysema
Interventions	LVRS versus medical care
Outcomes	Quality of life, lung function, mortality, exercise capacity
Starting date
Contact information
Notes	Interim analysis of data presented at 2001 ATS conference.

Strange 2007

Trial name or title
Methods
Participants
Interventions
Outcomes
Starting date
Contact information
Notes

Vaughan 2004

Trial name or title
Methods
Participants
Interventions	LVRS versus usual care (including pulmonary rehabilitation)
Outcomes
Starting date
Contact information
Notes

Data and analyses

Open in table viewer

Comparison 1. Surgery versus control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Overall mortality (all patients, to end of follow‐up) Show forest plot	5	1503	Odds Ratio (M‐H, Fixed, 95% CI)	1.06 [0.83, 1.35]
Open in figure viewer Analysis 1.1 Comparison 1 Surgery versus control, Outcome 1 Overall mortality (all patients, to end of follow‐up).
2 Overall mortality (stratified by risk, to end of follow‐up) Show forest plot	5	1503	Odds Ratio (M‐H, Fixed, 95% CI)	1.06 [0.83, 1.36]
Open in figure viewer Analysis 1.2 Comparison 1 Surgery versus control, Outcome 2 Overall mortality (stratified by risk, to end of follow‐up).
2.1 High risk	1	140	Odds Ratio (M‐H, Fixed, 95% CI)	2.0 [1.02, 3.92]
2.2 Non‐high risk	1	1078	Odds Ratio (M‐H, Fixed, 95% CI)	0.86 [0.64, 1.14]
2.3 Unclear risk status	4	285	Odds Ratio (M‐H, Fixed, 95% CI)	2.34 [0.98, 5.57]
3 30 Day Mortality in Non‐High Risk Patients Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.3 Comparison 1 Surgery versus control, Outcome 3 30 Day Mortality in Non‐High Risk Patients.
4 90‐Day Mortality (all patients) Show forest plot	4	1415	Odds Ratio (M‐H, Fixed, 95% CI)	6.57 [3.34, 12.95]
Open in figure viewer Analysis 1.4 Comparison 1 Surgery versus control, Outcome 4 90‐Day Mortality (all patients).
5 90‐Day Mortality (stratified by risk) Show forest plot	4	1415	Odds Ratio (M‐H, Fixed, 95% CI)	6.24 [3.24, 12.02]
Open in figure viewer Analysis 1.5 Comparison 1 Surgery versus control, Outcome 5 90‐Day Mortality (stratified by risk).
5.1 High risk	1	140	Odds Ratio (M‐H, Fixed, 95% CI)	57.24 [3.38, 968.54]
5.2 Non‐high risk	1	1078	Odds Ratio (M‐H, Fixed, 95% CI)	3.65 [1.65, 8.09]
5.3 Unclear risk status	3	197	Odds Ratio (M‐H, Fixed, 95% CI)	7.08 [1.54, 32.58]
6 Change in SGRQ (six months) Show forest plot	2		SGRQ (Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.6 Comparison 1 Surgery versus control, Outcome 6 Change in SGRQ (six months).
6.1 Symptoms	1		SGRQ (Fixed, 95% CI)	‐11.7 [‐20.15, ‐3.25]
6.2 Activity	1		SGRQ (Fixed, 95% CI)	‐16.8 [‐23.10, ‐10.50]
6.3 Impacts	1		SGRQ (Fixed, 95% CI)	‐13.1 [‐19.20, ‐7.00]
6.4 Total	2		SGRQ (Fixed, 95% CI)	‐13.49 [‐15.13, ‐11.84]
7 Change in SGRQ (12 months) Show forest plot	2		SGRQ units (Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.7 Comparison 1 Surgery versus control, Outcome 7 Change in SGRQ (12 months).
7.1 Symptoms	1		SGRQ units (Fixed, 95% CI)	‐8.8 [‐17.57, ‐0.03]
7.2 Activity	1		SGRQ units (Fixed, 95% CI)	‐17.1 [‐22.65, ‐11.55]
7.3 Impacts	1		SGRQ units (Fixed, 95% CI)	‐14.6 [‐20.05, ‐9.15]
7.4 Total	2		SGRQ units (Fixed, 95% CI)	‐13.78 [‐15.75, ‐11.80]
8 Change in SGRQ (24 months) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.8 Comparison 1 Surgery versus control, Outcome 8 Change in SGRQ (24 months).
8.1 Symptoms	0		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
8.2 Activity	0		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
8.3 Impacts	0		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
8.4 Total	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
9 Mean change in CRDQ domains (12 months) Show forest plot	1		CRDQ units (Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.9 Comparison 1 Surgery versus control, Outcome 9 Mean change in CRDQ domains (12 months).
9.1 Dypnoea	1		CRDQ units (Fixed, 95% CI)	0.0 [0.0, 0.0]
9.2 Fatigue	1		CRDQ units (Fixed, 95% CI)	0.0 [0.0, 0.0]
9.3 Mastery	1		CRDQ units (Fixed, 95% CI)	0.0 [0.0, 0.0]
9.4 Emotion	1		CRDQ units (Fixed, 95% CI)	0.0 [0.0, 0.0]
10 Mean change in CRDQ domains (24 months) Show forest plot	1		CRDQ units (Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.10 Comparison 1 Surgery versus control, Outcome 10 Mean change in CRDQ domains (24 months).
10.1 Dypnoea	1		CRDQ units (Fixed, 95% CI)	0.0 [0.0, 0.0]
10.2 Fatigue	1		CRDQ units (Fixed, 95% CI)	0.0 [0.0, 0.0]
10.3 Mastery	1		CRDQ units (Fixed, 95% CI)	0.0 [0.0, 0.0]
10.4 Emotion	1		CRDQ units (Fixed, 95% CI)	0.0 [0.0, 0.0]
11 Change in SF‐36 (six months) Show forest plot	1		SF‐346 units (Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.11 Comparison 1 Surgery versus control, Outcome 11 Change in SF‐36 (six months).
11.1 Physical functioning	1		SF‐346 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
11.2 Role physical	1		SF‐346 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
11.3 Bodily pain	1		SF‐346 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
11.4 General health	1		SF‐346 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
11.5 Vitality	1		SF‐346 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
11.6 Social functioning	1		SF‐346 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
11.7 Role emotional	1		SF‐346 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
11.8 Mental health	1		SF‐346 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
12 Change in SF‐36 (12 months) Show forest plot	1		SF‐36 units (Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.12 Comparison 1 Surgery versus control, Outcome 12 Change in SF‐36 (12 months).
12.1 Physical functioning	1		SF‐36 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
12.2 Role physical	1		SF‐36 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
12.3 Bodily pain	1		SF‐36 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
12.4 General health	1		SF‐36 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
12.5 Vitality	1		SF‐36 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
12.6 Social functioning	1		SF‐36 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
12.7 Role emotional	1		SF‐36 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
12.8 Mental health	1		SF‐36 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
13 Improvement in health‐related quality of life (SGRQ) Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.13 Comparison 1 Surgery versus control, Outcome 13 Improvement in health‐related quality of life (SGRQ).
13.1 Six months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
13.2 12 months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
13.3 24 months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
14 No change/deterioration in health‐related quality of life (SGRQ) Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.14 Comparison 1 Surgery versus control, Outcome 14 No change/deterioration in health‐related quality of life (SGRQ).
14.1 Six months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
14.2 12 months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
14.3 24 months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
15 Improvement in exercise capacity Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.15 Comparison 1 Surgery versus control, Outcome 15 Improvement in exercise capacity.
15.1 Six months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
15.2 12 months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
15.3 24 months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
16 No change/deterioration in exercise capacity Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.16 Comparison 1 Surgery versus control, Outcome 16 No change/deterioration in exercise capacity.
16.1 Six months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
16.2 12 months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
16.3 24 months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
17 Six minute walk distance (metres) Show forest plot	3		Mean Difference (IV, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.17 Comparison 1 Surgery versus control, Outcome 17 Six minute walk distance (metres).
17.1 at 3 months	2	80	Mean Difference (IV, Fixed, 95% CI)	20.85 [‐9.36, 51.07]
17.2 at 6 months	1	81	Mean Difference (IV, Fixed, 95% CI)	55.0 [9.58, 100.42]
17.3 at 12 months	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
18 Change in six minute walk distance (metres) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.18 Comparison 1 Surgery versus control, Outcome 18 Change in six minute walk distance (metres).
18.1 at 3 months	0		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
18.2 at 6 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
18.3 at 12 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
18.4 at 24 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
19 FEV1 (L) Show forest plot	5		Mean Difference (IV, Fixed, 95% CI)	Subtotals only
Open in figure viewer Analysis 1.19 Comparison 1 Surgery versus control, Outcome 19 FEV1 (L).
19.1 at 3 months	3	122	Mean Difference (IV, Fixed, 95% CI)	0.23 [0.08, 0.37]
19.2 at 6 months	4	248	Mean Difference (IV, Fixed, 95% CI)	0.28 [0.20, 0.35]
19.3 at 12 months	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
20 Improvement in FEV1 % predicted Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.20 Comparison 1 Surgery versus control, Outcome 20 Improvement in FEV1 % predicted.
20.1 Six months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
20.2 12 months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
20.3 24 months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
21 No change/deterioration in FEV1 % predicted Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.21 Comparison 1 Surgery versus control, Outcome 21 No change/deterioration in FEV1 % predicted.
21.1 Six months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
21.2 12 months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
21.3 24 months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
22 Change in FEV1 (% predicted) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.22 Comparison 1 Surgery versus control, Outcome 22 Change in FEV1 (% predicted).
22.1 at 3 months	0		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
22.2 at 6 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
22.3 at 12 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
22.4 at 24 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
23 Total lung capacity (% of predicted) Show forest plot	3	122	Mean Difference (IV, Fixed, 95% CI)	‐21.70 [‐30.97, ‐12.43]
Open in figure viewer Analysis 1.23 Comparison 1 Surgery versus control, Outcome 23 Total lung capacity (% of predicted).
23.1 at 3 months	3	122	Mean Difference (IV, Fixed, 95% CI)	‐21.70 [‐30.97, ‐12.43]
23.2 at 6 months	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
23.3 at 12 months	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
24 Residual lung volume (% of predicted) Show forest plot	3	122	Mean Difference (IV, Fixed, 95% CI)	‐54.52 [‐75.17, ‐33.88]
Open in figure viewer Analysis 1.24 Comparison 1 Surgery versus control, Outcome 24 Residual lung volume (% of predicted).
24.1 at 3 months	3	122	Mean Difference (IV, Fixed, 95% CI)	‐54.52 [‐75.17, ‐33.88]
24.2 at 6 months	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
24.3 at 12 months	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
25 Mean direct medical costs and total healthcare‐related costs according to time after randomisation (USD 000s) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.25 Comparison 1 Surgery versus control, Outcome 25 Mean direct medical costs and total healthcare‐related costs according to time after randomisation (USD 000s).
25.1 Direct Medical Costs 0‐12 Months after randomisation (USD 000s)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
25.2 Total Costs 0‐12 months after randomisation (USD 000s)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
25.3 Direct medical costs 13‐24 months after randomisation (USD 000s)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
25.4 Total costs 13‐24 months after randomisation (USD 000s)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
25.5 Direct medical costs 25‐36 months after randomisation (USD 000s)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
25.6 Total costs 25‐36 months after randomisation (USD 000s)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
26 Mean direct medical costs and total healthcare‐related costs at three years (USD 000s) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.26 Comparison 1 Surgery versus control, Outcome 26 Mean direct medical costs and total healthcare‐related costs at three years (USD 000s).
27 Mean number of emergency‐room visits Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 1.27 Comparison 1 Surgery versus control, Outcome 27 Mean number of emergency‐room visits.
27.1 0‐12 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
27.2 13‐24 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
27.3 25‐36 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

Open in table viewer

Comparison 2. Laser versus stapling

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Post‐operative Death Show forest plot	1		Peto Odds Ratio (Peto, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.1 Comparison 2 Laser versus stapling, Outcome 1 Post‐operative Death.
2 Hospital Days Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.2 Comparison 2 Laser versus stapling, Outcome 2 Hospital Days.
3 Persistent air leaks (>7days) Show forest plot	1		Peto Odds Ratio (Peto, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.3 Comparison 2 Laser versus stapling, Outcome 3 Persistent air leaks (>7days).
4 Delayed Pneumothorax Show forest plot	1		Peto Odds Ratio (Peto, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.4 Comparison 2 Laser versus stapling, Outcome 4 Delayed Pneumothorax.
5 Supplemental Oxygen Show forest plot	1		Peto Odds Ratio (Peto, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.5 Comparison 2 Laser versus stapling, Outcome 5 Supplemental Oxygen.
6 Quality of Life Show forest plot	1		Peto Odds Ratio (Peto, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.6 Comparison 2 Laser versus stapling, Outcome 6 Quality of Life.
7 Change in FEV1 (%) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.7 Comparison 2 Laser versus stapling, Outcome 7 Change in FEV1 (%).
8 Change in FVC (%) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 2.8 Comparison 2 Laser versus stapling, Outcome 8 Change in FVC (%).

Open in table viewer

Comparison 3. Buttressed versus non‐buttressed stapling

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mortality	0		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected
2 Hospital stay (days) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 3.2 Comparison 3 Buttressed versus non‐buttressed stapling, Outcome 2 Hospital stay (days).
3 Post‐operative air leak Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 3.3 Comparison 3 Buttressed versus non‐buttressed stapling, Outcome 3 Post‐operative air leak.
4 Re‐operations following persistent air leak Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 3.4 Comparison 3 Buttressed versus non‐buttressed stapling, Outcome 4 Re‐operations following persistent air leak.
5 FEV1 (% predicted) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 3.5 Comparison 3 Buttressed versus non‐buttressed stapling, Outcome 5 FEV1 (% predicted).
6 Residual volume (% predicted) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 3.6 Comparison 3 Buttressed versus non‐buttressed stapling, Outcome 6 Residual volume (% predicted).
7 Total lung capacity (% predicted) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected
Open in figure viewer Analysis 3.7 Comparison 3 Buttressed versus non‐buttressed stapling, Outcome 7 Total lung capacity (% predicted).

Figure 1

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

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Figure 2

Forest plot of comparison: 1 Surgery versus control, outcome: 1.1 Overall mortality (all patients, to end of follow‐up).

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Figure 3

At 90 days one extra death occurs following LVRS, for every 16 people operated on.

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Figure 4

At 90 days one extra death occurs following LVRS, for every 27 people operated on in the low risk arm of the NETT trial.

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Analysis 1.1

Comparison 1 Surgery versus control, Outcome 1 Overall mortality (all patients, to end of follow‐up).

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Analysis 1.2

Comparison 1 Surgery versus control, Outcome 2 Overall mortality (stratified by risk, to end of follow‐up).

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Analysis 1.3

Comparison 1 Surgery versus control, Outcome 3 30 Day Mortality in Non‐High Risk Patients.

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Analysis 1.4

Comparison 1 Surgery versus control, Outcome 4 90‐Day Mortality (all patients).

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Analysis 1.5

Comparison 1 Surgery versus control, Outcome 5 90‐Day Mortality (stratified by risk).

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Analysis 1.6

Comparison 1 Surgery versus control, Outcome 6 Change in SGRQ (six months).

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Analysis 1.7

Comparison 1 Surgery versus control, Outcome 7 Change in SGRQ (12 months).

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Analysis 1.8

Comparison 1 Surgery versus control, Outcome 8 Change in SGRQ (24 months).

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Analysis 1.9

Comparison 1 Surgery versus control, Outcome 9 Mean change in CRDQ domains (12 months).

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Analysis 1.10

Comparison 1 Surgery versus control, Outcome 10 Mean change in CRDQ domains (24 months).

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Analysis 1.11

Comparison 1 Surgery versus control, Outcome 11 Change in SF‐36 (six months).

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Analysis 1.12

Comparison 1 Surgery versus control, Outcome 12 Change in SF‐36 (12 months).

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Analysis 1.13

Comparison 1 Surgery versus control, Outcome 13 Improvement in health‐related quality of life (SGRQ).

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Analysis 1.14

Comparison 1 Surgery versus control, Outcome 14 No change/deterioration in health‐related quality of life (SGRQ).

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Analysis 1.15

Comparison 1 Surgery versus control, Outcome 15 Improvement in exercise capacity.

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Analysis 1.16

Comparison 1 Surgery versus control, Outcome 16 No change/deterioration in exercise capacity.

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Analysis 1.17

Comparison 1 Surgery versus control, Outcome 17 Six minute walk distance (metres).

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Analysis 1.18

Comparison 1 Surgery versus control, Outcome 18 Change in six minute walk distance (metres).

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Analysis 1.19

Comparison 1 Surgery versus control, Outcome 19 FEV1 (L).

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Analysis 1.20

Comparison 1 Surgery versus control, Outcome 20 Improvement in FEV1 % predicted.

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Analysis 1.21

Comparison 1 Surgery versus control, Outcome 21 No change/deterioration in FEV1 % predicted.

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Analysis 1.22

Comparison 1 Surgery versus control, Outcome 22 Change in FEV1 (% predicted).

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Analysis 1.23

Comparison 1 Surgery versus control, Outcome 23 Total lung capacity (% of predicted).

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Analysis 1.24

Comparison 1 Surgery versus control, Outcome 24 Residual lung volume (% of predicted).

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Analysis 1.25

Comparison 1 Surgery versus control, Outcome 25 Mean direct medical costs and total healthcare‐related costs according to time after randomisation (USD 000s).

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Analysis 1.26

Comparison 1 Surgery versus control, Outcome 26 Mean direct medical costs and total healthcare‐related costs at three years (USD 000s).

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Analysis 1.27

Comparison 1 Surgery versus control, Outcome 27 Mean number of emergency‐room visits.

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Analysis 2.1

Comparison 2 Laser versus stapling, Outcome 1 Post‐operative Death.

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Analysis 2.2

Comparison 2 Laser versus stapling, Outcome 2 Hospital Days.

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Analysis 2.3

Comparison 2 Laser versus stapling, Outcome 3 Persistent air leaks (>7days).

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Analysis 2.4

Comparison 2 Laser versus stapling, Outcome 4 Delayed Pneumothorax.

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Analysis 2.5

Comparison 2 Laser versus stapling, Outcome 5 Supplemental Oxygen.

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Analysis 2.6

Comparison 2 Laser versus stapling, Outcome 6 Quality of Life.

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Analysis 2.7

Comparison 2 Laser versus stapling, Outcome 7 Change in FEV1 (%).

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Analysis 2.8

Comparison 2 Laser versus stapling, Outcome 8 Change in FVC (%).

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Analysis 3.2

Comparison 3 Buttressed versus non‐buttressed stapling, Outcome 2 Hospital stay (days).

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Analysis 3.3

Comparison 3 Buttressed versus non‐buttressed stapling, Outcome 3 Post‐operative air leak.

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Analysis 3.4

Comparison 3 Buttressed versus non‐buttressed stapling, Outcome 4 Re‐operations following persistent air leak.

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Analysis 3.5

Comparison 3 Buttressed versus non‐buttressed stapling, Outcome 5 FEV1 (% predicted).

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Analysis 3.6

Comparison 3 Buttressed versus non‐buttressed stapling, Outcome 6 Residual volume (% predicted).

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Analysis 3.7

Comparison 3 Buttressed versus non‐buttressed stapling, Outcome 7 Total lung capacity (% predicted).

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Table 1. Search history

Search dates	Detail
1. All years to December 1999	References identified: 65 Full text articles retrieved: 13 Unique studies identified: 13 Studies failing to meet review entry criteria: 12 Studies meeting entry criteria: 1
2. December 1999 to September 2005	References identified: 253 Full text articles retrieved: 45 Unique studies identified: 11 Studies failing to meet review entry criteria: 4 Studies meeting entry criteria: 7 Total number of included studies (sum previous number & new included studies): 8
3. September 2005 to October 2006	References identified: 24 Full text articles retrieved: 7 Unique studies identified: 0 (the references were subsequent publications of either NETT 2003 or Hillerdal 2005)
4. October 2006 to September 2007	References identified: 7 Full text articles retrieved: 3 Unique studies identified: 0 (the references were subsequent publications of NETT 2003)

Table 1. Search history

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Table 2. Study populations

Study ID	Screened	Entered (% Screened)
Criner 1999	200	37 (19)
Geddes 2000	174	48 (28)
Goldstein 2003	328	55 (17)
Hillerdal 2005	304	106 (35)
McKenna 1996	Unclear	72 (unclear)
Miller 2005	738	93 (13)
NETT 2001	3777	1218 (32)
Stammberger 2000	Unclear	74 (unclear)
Total	5521	1520 (28)* *Excludes data from McKenna 1996 & Stammberger 2000

Table 2. Study populations

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Table 3. Mortality at 90 days: NNT ‐ stratified by baseline risk status

Subgroup (OR)	Studies	N (combined)	CGER	NNT(h)
NETT defined 'high risk'	NETT 2001	140	0%	4
NETT defined 'non‐high risk'	NETT 2001	1078	25%	27
Unclear risk status	Geddes 2003; Goldstein 2003; Hillerdal 2005	285	1%	9

Table 3. Mortality at 90 days: NNT ‐ stratified by baseline risk status

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Table 4. Overall mortality: NNT ‐ stratified by baseline risk status

Subgroup (OR)	Studies	N (combined)	CGER	NNT (h)
NETT defined 'high risk' ‐ OR 2 (1.02 to 3.92)	NETT 2001	140	43%	6
NETT defined 'non‐high risk' ‐ 0.86 (0.64 to 1.14)	NETT 2001	1078	24%	NS
Unclear risk status ‐ OR: 2.21 (1 to 4.9)	Geddes 2000; Goldstein 2003; Hillerdal 2005; Miller 2005	285	8%	NS

Table 4. Overall mortality: NNT ‐ stratified by baseline risk status

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Comparison 1. Surgery versus control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Overall mortality (all patients, to end of follow‐up) Show forest plot	5	1503	Odds Ratio (M‐H, Fixed, 95% CI)	1.06 [0.83, 1.35]

2 Overall mortality (stratified by risk, to end of follow‐up) Show forest plot	5	1503	Odds Ratio (M‐H, Fixed, 95% CI)	1.06 [0.83, 1.36]

2.1 High risk	1	140	Odds Ratio (M‐H, Fixed, 95% CI)	2.0 [1.02, 3.92]
2.2 Non‐high risk	1	1078	Odds Ratio (M‐H, Fixed, 95% CI)	0.86 [0.64, 1.14]
2.3 Unclear risk status	4	285	Odds Ratio (M‐H, Fixed, 95% CI)	2.34 [0.98, 5.57]
3 30 Day Mortality in Non‐High Risk Patients Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

4 90‐Day Mortality (all patients) Show forest plot	4	1415	Odds Ratio (M‐H, Fixed, 95% CI)	6.57 [3.34, 12.95]

5 90‐Day Mortality (stratified by risk) Show forest plot	4	1415	Odds Ratio (M‐H, Fixed, 95% CI)	6.24 [3.24, 12.02]

5.1 High risk	1	140	Odds Ratio (M‐H, Fixed, 95% CI)	57.24 [3.38, 968.54]
5.2 Non‐high risk	1	1078	Odds Ratio (M‐H, Fixed, 95% CI)	3.65 [1.65, 8.09]
5.3 Unclear risk status	3	197	Odds Ratio (M‐H, Fixed, 95% CI)	7.08 [1.54, 32.58]
6 Change in SGRQ (six months) Show forest plot	2		SGRQ (Fixed, 95% CI)	Subtotals only

6.1 Symptoms	1		SGRQ (Fixed, 95% CI)	‐11.7 [‐20.15, ‐3.25]
6.2 Activity	1		SGRQ (Fixed, 95% CI)	‐16.8 [‐23.10, ‐10.50]
6.3 Impacts	1		SGRQ (Fixed, 95% CI)	‐13.1 [‐19.20, ‐7.00]
6.4 Total	2		SGRQ (Fixed, 95% CI)	‐13.49 [‐15.13, ‐11.84]
7 Change in SGRQ (12 months) Show forest plot	2		SGRQ units (Fixed, 95% CI)	Subtotals only

7.1 Symptoms	1		SGRQ units (Fixed, 95% CI)	‐8.8 [‐17.57, ‐0.03]
7.2 Activity	1		SGRQ units (Fixed, 95% CI)	‐17.1 [‐22.65, ‐11.55]
7.3 Impacts	1		SGRQ units (Fixed, 95% CI)	‐14.6 [‐20.05, ‐9.15]
7.4 Total	2		SGRQ units (Fixed, 95% CI)	‐13.78 [‐15.75, ‐11.80]
8 Change in SGRQ (24 months) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

8.1 Symptoms	0		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
8.2 Activity	0		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
8.3 Impacts	0		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
8.4 Total	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
9 Mean change in CRDQ domains (12 months) Show forest plot	1		CRDQ units (Fixed, 95% CI)	Totals not selected

9.1 Dypnoea	1		CRDQ units (Fixed, 95% CI)	0.0 [0.0, 0.0]
9.2 Fatigue	1		CRDQ units (Fixed, 95% CI)	0.0 [0.0, 0.0]
9.3 Mastery	1		CRDQ units (Fixed, 95% CI)	0.0 [0.0, 0.0]
9.4 Emotion	1		CRDQ units (Fixed, 95% CI)	0.0 [0.0, 0.0]
10 Mean change in CRDQ domains (24 months) Show forest plot	1		CRDQ units (Fixed, 95% CI)	Totals not selected

10.1 Dypnoea	1		CRDQ units (Fixed, 95% CI)	0.0 [0.0, 0.0]
10.2 Fatigue	1		CRDQ units (Fixed, 95% CI)	0.0 [0.0, 0.0]
10.3 Mastery	1		CRDQ units (Fixed, 95% CI)	0.0 [0.0, 0.0]
10.4 Emotion	1		CRDQ units (Fixed, 95% CI)	0.0 [0.0, 0.0]
11 Change in SF‐36 (six months) Show forest plot	1		SF‐346 units (Fixed, 95% CI)	Totals not selected

11.1 Physical functioning	1		SF‐346 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
11.2 Role physical	1		SF‐346 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
11.3 Bodily pain	1		SF‐346 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
11.4 General health	1		SF‐346 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
11.5 Vitality	1		SF‐346 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
11.6 Social functioning	1		SF‐346 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
11.7 Role emotional	1		SF‐346 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
11.8 Mental health	1		SF‐346 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
12 Change in SF‐36 (12 months) Show forest plot	1		SF‐36 units (Fixed, 95% CI)	Totals not selected

12.1 Physical functioning	1		SF‐36 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
12.2 Role physical	1		SF‐36 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
12.3 Bodily pain	1		SF‐36 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
12.4 General health	1		SF‐36 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
12.5 Vitality	1		SF‐36 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
12.6 Social functioning	1		SF‐36 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
12.7 Role emotional	1		SF‐36 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
12.8 Mental health	1		SF‐36 units (Fixed, 95% CI)	0.0 [0.0, 0.0]
13 Improvement in health‐related quality of life (SGRQ) Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

13.1 Six months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
13.2 12 months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
13.3 24 months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
14 No change/deterioration in health‐related quality of life (SGRQ) Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

14.1 Six months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
14.2 12 months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
14.3 24 months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
15 Improvement in exercise capacity Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

15.1 Six months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
15.2 12 months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
15.3 24 months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
16 No change/deterioration in exercise capacity Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

16.1 Six months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
16.2 12 months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
16.3 24 months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
17 Six minute walk distance (metres) Show forest plot	3		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

17.1 at 3 months	2	80	Mean Difference (IV, Fixed, 95% CI)	20.85 [‐9.36, 51.07]
17.2 at 6 months	1	81	Mean Difference (IV, Fixed, 95% CI)	55.0 [9.58, 100.42]
17.3 at 12 months	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
18 Change in six minute walk distance (metres) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

18.1 at 3 months	0		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
18.2 at 6 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
18.3 at 12 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
18.4 at 24 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
19 FEV1 (L) Show forest plot	5		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

19.1 at 3 months	3	122	Mean Difference (IV, Fixed, 95% CI)	0.23 [0.08, 0.37]
19.2 at 6 months	4	248	Mean Difference (IV, Fixed, 95% CI)	0.28 [0.20, 0.35]
19.3 at 12 months	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
20 Improvement in FEV1 % predicted Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

20.1 Six months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
20.2 12 months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
20.3 24 months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
21 No change/deterioration in FEV1 % predicted Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

21.1 Six months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
21.2 12 months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
21.3 24 months	1		Odds Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
22 Change in FEV1 (% predicted) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

22.1 at 3 months	0		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
22.2 at 6 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
22.3 at 12 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
22.4 at 24 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
23 Total lung capacity (% of predicted) Show forest plot	3	122	Mean Difference (IV, Fixed, 95% CI)	‐21.70 [‐30.97, ‐12.43]

23.1 at 3 months	3	122	Mean Difference (IV, Fixed, 95% CI)	‐21.70 [‐30.97, ‐12.43]
23.2 at 6 months	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
23.3 at 12 months	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
24 Residual lung volume (% of predicted) Show forest plot	3	122	Mean Difference (IV, Fixed, 95% CI)	‐54.52 [‐75.17, ‐33.88]

24.1 at 3 months	3	122	Mean Difference (IV, Fixed, 95% CI)	‐54.52 [‐75.17, ‐33.88]
24.2 at 6 months	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
24.3 at 12 months	0	0	Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
25 Mean direct medical costs and total healthcare‐related costs according to time after randomisation (USD 000s) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

25.1 Direct Medical Costs 0‐12 Months after randomisation (USD 000s)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
25.2 Total Costs 0‐12 months after randomisation (USD 000s)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
25.3 Direct medical costs 13‐24 months after randomisation (USD 000s)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
25.4 Total costs 13‐24 months after randomisation (USD 000s)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
25.5 Direct medical costs 25‐36 months after randomisation (USD 000s)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
25.6 Total costs 25‐36 months after randomisation (USD 000s)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
26 Mean direct medical costs and total healthcare‐related costs at three years (USD 000s) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

27 Mean number of emergency‐room visits Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

27.1 0‐12 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
27.2 13‐24 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
27.3 25‐36 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 1. Surgery versus control

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Comparison 2. Laser versus stapling

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Post‐operative Death Show forest plot	1		Peto Odds Ratio (Peto, Fixed, 95% CI)	Totals not selected

2 Hospital Days Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3 Persistent air leaks (>7days) Show forest plot	1		Peto Odds Ratio (Peto, Fixed, 95% CI)	Totals not selected

4 Delayed Pneumothorax Show forest plot	1		Peto Odds Ratio (Peto, Fixed, 95% CI)	Totals not selected

5 Supplemental Oxygen Show forest plot	1		Peto Odds Ratio (Peto, Fixed, 95% CI)	Totals not selected

6 Quality of Life Show forest plot	1		Peto Odds Ratio (Peto, Fixed, 95% CI)	Totals not selected

7 Change in FEV1 (%) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

8 Change in FVC (%) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 2. Laser versus stapling

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Comparison 3. Buttressed versus non‐buttressed stapling

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mortality	0		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected
2 Hospital stay (days) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3 Post‐operative air leak Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

4 Re‐operations following persistent air leak Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

5 FEV1 (% predicted) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

6 Residual volume (% predicted) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

7 Total lung capacity (% predicted) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 3. Buttressed versus non‐buttressed stapling

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Referencias

Referencias de los estudios incluidos en esta revisión

Criner 1999 {published data only}

Geddes 2000 {published data only}

Goldstein 2003 {published data only}

Hillerdal 2005 {published data only}

McKenna 1996 {published data only}

Miller 2005 {published data only}

NETT {published data only}

Stammberger 2000 {published data only}

Referencias de los estudios excluidos de esta revisión

Daniel 1996 {published data only}

Keenan 1996 {published data only}

Kotloff 1996 {published data only}

Little 1995 {published data only}

Martinez 1997 {published data only}

Nickoladze 1992 {published data only}

O'Brien 1999 {published data only}

Pompeo 2000 {published data only}

Sciurba 1996 {published data only}

Szekely 1997 {published data only}

Tan 2000 {published data only}

Teschler 1996 {published data only}

Wakabayashi 1995 {published data only}

Referencias de los estudios en curso

Goodnight 2001 {published data only}

Strange 2007 {published data only}

Vaughan 2004 {published data only (unpublished sought but not used)}

Referencias adicionales

Burge 2000

Cockram 2006

Garrod 2006

Higgins 2003

Holohan 1996

Jones 2002

Lacasse 2006

NETT 2001a

NICE 2002

NICE/BTS 2004

Ramsey 2005

Ries 2005

Singh 1998

Yusen 1996

Yusen 2003

Referencias de otras versiones publicadas de esta revisión

Hensley 1999

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Characteristics of excluded studies [ordered by study ID]

Characteristics of ongoing studies [ordered by study ID]

Data and analyses

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