Enzymatic therapy versus video-assisted thoracoscopic surgery for pleural infections: a systematic review and meta-analysis

Aims Parapneumonic pleural infections are frequently encountered, but the optimal treatment regimen remains controversial. The aim of this systematic review was to investigate whether immediate video-assisted thoracoscopic surgery (VATS) has advantages over intrapleural enzymatic therapy (IET). Methods We searched MEDLINE, Embase and Web of Science Core Collection till November 2023 and included studies comparing IET and VATS in adult patients with parapneumonic pleural infections. Primary outcome was length of hospital stay (LOS); secondary outcomes included mortality and morbidity. Study quality was assessed using ROBINS-I and RoB 2. Inverse variance random-effects meta-analysis was performed. Results We screened 2263 articles; eight were included in the final analysis, covering 1023 patients (n=465 IET (mostly single agent IET); n=558 VATS). Six were non-randomised studies (n=5 with serious risk of bias) comprising 964 patients, and two were small, randomised feasibility studies (n=1 with high risk of bias), comprising 59 patients. In the meta-analysis, LOS in non-randomised studies was shorter for patients treated by VATS (mean difference 4.2 days; 95% CI 1.5–7.0). However, no significant difference was reported in the randomised feasibility studies. Mortality and morbidity rates showed no significant difference. Interpretation In this meta-analysis of non-randomised studies with a high risk of selection bias, VATS appears superior to IET regarding LOS in the treatment of parapneumonic pleural infections, without increased mortality and morbidity rate. Two recently published randomised feasibility studies failed to confirm this finding, but were not designed to detect a difference in LOS. This meta-analysis highlights the need for high-quality studies.