Intrapleural Fibrinolytics Versus Thoracic Surgery for Complicated Pleural Infections: A Systematic Review and Meta-Analysis

BACKGROUND: Intrapleural fibrinolytic therapy (IPFT) is an option for complicated pleural effusion (CPE). However, concerns remain about its use compared with thoracic surgery (TS). Therefore, we conducted a systematic review and meta-analysis to assess the length of stay associated with IPFT compared to TS in treating CPE. METHOD: We searched PubMed, Embase, and Cochrane Library databases for studies that compared TS with IPFT in patients with complicated pleural infections. We used a random-effects model with a 95% confidence interval (CI) to pool the data. R version 4.4.1 was used for statistical analysis and heterogeneity was examined using I2 statistics. RESULTS: A total of 16 studies, including 13 randomised controlled trials, involving a total of 764 were analysed. Of whom, 40% underwent IPFT. The success rate was higher in the TS group (odds ratio 0.3; 95% CI 0.11-0.78; p=0.014; I2=47%), and had a significantly shorter length of stay (mean difference 2.76; 95% CI 1.40-4.13; p<0.001; I2=92%) compared with the IPFT group. There were no statistical differences between groups in the mortality endpoint. Considering only the paediatric population, there were also no statistically significant differences for length of stay (mean difference 1.32; 95% CI -2.37 to 5.01; p=0.08; I2=91%) or success rates (odds ratio 0.86; 95% CI 0.27-2.74; p=0.74; I2=0%). CONCLUSIONS: Our findings suggest that TS is an effective treatment for pleural infections. There is no significant increase in adverse events, and both treatments are equally effective and safe.