Surgical versus non‐surgical management for pleural empyema

Mark D Redden; Tze Yang Chin; Mieke L van Driel

doi:10.1002/14651858.CD010651.pub2

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Figure 1

Study flow diagram.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

Comparison 1 Open thoracotomy versus thoracostomy drainage, Outcome 1 Mortality.

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Analysis 1.2

Comparison 1 Open thoracotomy versus thoracostomy drainage, Outcome 2 Length of hospital stay (days).

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Analysis 1.3

Comparison 1 Open thoracotomy versus thoracostomy drainage, Outcome 3 Procedural complications.

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Analysis 2.1

Comparison 2 VATS versus thoracostomy drainage, Outcome 1 Mortality.

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Analysis 2.2

Comparison 2 VATS versus thoracostomy drainage, Outcome 2 Length of hospital stay (days).

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Analysis 2.3

Comparison 2 VATS versus thoracostomy drainage, Outcome 3 Procedural complications.

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Summary of findings for the main comparison. Open thoracotomy compared to thoracostomy drainage for pleural empyema

Open thoracotomy compared to thoracostomy drainage for pleural empyema
Patient or population: children with pleural empyema Intervention: open thoracotomy Comparison: thoracostomy drainage
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Thoracostomy drainage	Open thoracotomy
Mortality Follow‐up: up to 3 months after discharge	Risk in study population		Not estimable	30 (1 RCT)	⊕⊕⊕⊝ MODERATE ¹	No deaths occurred in either group.
	—	—
Length of hospital stay (days) Follow‐up: up to 3 months after discharge	The mean length of hospital stay in the control group was 15.4 days.	The mean length of hospital stay in the intervention group was 5.9 days fewer (7.29 fewer to 4.51 fewer).	—	30 (1 RCT)	⊕⊕⊕⊝ MODERATE¹
Procedural complications Follow‐up: up to 3 months after discharge	Risk in study population		OR 0.10 (0.02 to 0.63)	30 (1 RCT)	⊕⊕⊕⊝ MODERATE ¹
	600 per 1000	130 per 1000 (29 to 486)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; OR: odds ratio; RCT: randomised controlled trial
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect. Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.
¹Downgraded one level due to small sample size and only one study.

Summary of findings for the main comparison. Open thoracotomy compared to thoracostomy drainage for pleural empyema

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Summary of findings 2. VATS compared to thoracostomy drainage for pleural empyema

VATS compared to thoracostomy drainage for pleural empyema
Patient or population: children and adults with pleural empyema Intervention: VATS Comparison: thoracostomy drainage
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Thoracostomy drainage	VATS
Mortality	Risk in study population		OR 0.80 (0.04 to 14.89)	361 (7 RCTs)	⊕⊕⊝⊝ LOW¹	Data only for adults
	6 per 1000	5 per 1000 (0 to 78)
Mortality: children	Risk in study population		Not estimable	271 (5 RCTs)	⊕⊕⊕⊝ MODERATE ²	No deaths occurred in either group.
	Not pooled	Not pooled
Mortality: adults Follow‐up: not reported	Risk in study population		OR 0.80 (0.04 to 14.89)	90 (2 RCTs)	⊕⊕⊕⊝ MODERATE ³	No deaths occurred in Bilgin 2006. Data based on Wait 1997
	23 per 1000	18 per 1000 (1 to 257)
Length of hospital stay (days) Follow‐up: 1 year in Cobanoglu 2011 and 3 months in Marhuenda 2014	Control group	The mean length of hospital stay in the intervention group was 2.52 days fewer (4.26 fewer to 0.77 fewer).	—	231 (5 RCTs)	⊕⊕⊕⊝ MODERATE⁴	Note: Follow‐up period not reported in Kurt 2006; Peter 2009; Wait 1997.
Procedural complications Follow‐up: 6 months in Bilgin 2006 and not reported in Wait 1997	Risk in study population		OR 0.46 (0.08 to 2.75)	271 (5 RCTs)	⊕⊕⊕⊝ MODERATE ⁵
	23 per 1000	11 per 1000 (2 to 60)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; OR: odds ratio; RCT: randomised controlled trial; VATS: video‐assisted thoracoscopic surgery
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect. Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.
¹Downgraded two levels due to wide confidence intervals (data from only one study) and indirectness (data only available for adults). ²Downgraded one level as data not available due to small sample size and no events occurring in the studies. ³Downgraded one level due to small sample size (imprecision) as data available from only one study. ⁴Downgraded one level due to heterogeneity. ⁵Downgraded one level due to wide confidence intervals.

Summary of findings 2. VATS compared to thoracostomy drainage for pleural empyema

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Table 1. Total cost of treatment

Trial	Total treatment cost (USD): thoracostomy arm	Total treatment cost (USD): VATS arm	P value
Cobanoglu 2011	Mean 386.672 ± 72.06	Mean 957.487 ± 137.238	< 0.001
Kurt 2006	Median (IQR) 21,947 (17,895 to 37,458)	Median (IQR) 19,714 (17,325 to 23,000)	0.315
Sonnappa 2006	Mean 9127	Mean 11,379	< 0.001
Peter 2009	Mean 7600 ± 5400	Mean 11,700 ± 2900	0.02
Wait 1997	Mean 24,052 ± 3466	Mean 16,642 ± 2841	0.11
IQR: interquartile range

Table 1. Total cost of treatment

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Table 2. Duration of chest tube drainage

Trial	Duration of chest tube drainage: thoracostomy arm (days)	Duration of chest tube drainage: surgical arm (days)	P value
Cobanoglu 2011	Mean 9.48 ± 2.50	Mean 6.56 ± 1.55	< 0.001
Karaman 2004	Mean 13.8 ± 2.3	Mean 7.5 ± 1.1	< 0.05
Kurt 2006	Mean 9.63 ± 5.45	Mean 2.80 ± 0.63	< 0.001
Marhuenda 2014	Median (IQR) 5 (4 to 6)	Median (IQR) 4 (3 to 5)	< 0.001
Wait 1997	Mean 9.8 ± 1.3	Mean 5.8 ± 1.1	0.03
IQR: interquartile range

Table 2. Duration of chest tube drainage

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Table 3. Postintervention fever duration

Trial	Postintervention fever duration: thoracostomy arm (days)	Postintervention fever duration: surgical arm (days)	P value
Cobanoglu 2011	Mean 3.9 ± 2.1	Mean 3.4 ± 2.4	0.782
Kurt 2006	Mean 6.25 ± 4.10	Mean 3.60 ± 2.95	0.146
Marhuenda 2014	Median (IQR) 6 (3 to 7)	Median (IQR) 4 (2 to 7)	0.62
Sonnappa 2006	Median (range) 2.5 (0 to 25)	Median (range) 2.5 (0 to 10)	0.635
Peter 2009	Mean 3.8 ± 2.9	Mean 3.1 ± 2.7	0.46
IQR: interquartile range

Table 3. Postintervention fever duration

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Comparison 1. Open thoracotomy versus thoracostomy drainage

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mortality Show forest plot	1	30	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]

2 Length of hospital stay (days) Show forest plot	1	30	Mean Difference (IV, Random, 95% CI)	‐5.9 [‐7.29, ‐4.51]

3 Procedural complications Show forest plot	1	30	Odds Ratio (M‐H, Random, 95% CI)	0.10 [0.02, 0.63]

Comparison 1. Open thoracotomy versus thoracostomy drainage

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Comparison 2. VATS versus thoracostomy drainage

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mortality Show forest plot	7	361	Odds Ratio (M‐H, Random, 95% CI)	0.8 [0.04, 14.89]

1.1 Children	5	271	Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 Adults	2	90	Odds Ratio (M‐H, Random, 95% CI)	0.8 [0.04, 14.89]
2 Length of hospital stay (days) Show forest plot	5	231	Mean Difference (IV, Random, 95% CI)	‐2.52 [‐4.26, ‐0.77]

2.1 Children	4	211	Mean Difference (IV, Random, 95% CI)	‐1.99 [‐4.36, 0.39]
2.2 Adults	1	20	Mean Difference (IV, Random, 95% CI)	‐4.10 [‐4.99, ‐3.21]
3 Procedural complications Show forest plot	5	271	Odds Ratio (M‐H, Random, 95% CI)	0.46 [0.08, 2.75]

3.1 Children	3	181	Odds Ratio (M‐H, Random, 95% CI)	0.94 [0.06, 15.48]
3.2 Adults	2	90	Odds Ratio (M‐H, Random, 95% CI)	0.28 [0.03, 2.88]

Comparison 2. VATS versus thoracostomy drainage

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