Early versus late chest tube removal after surgery for primary spontaneous pneumothorax-a systematic review and meta-analysis.

Background: The optimal timing of postoperative chest tube removal remains disputable. Traditionally, chest tubes are left in place for several days for adequate pleurodesis and recurrence prevention after surgery for primary spontaneous pneumothorax (PSP). Currently, early tube removal, defined as immediate removal upon cessation of air leakage, is increasingly practiced. This study aimed to evaluate the safety of early chest tube removal in terms of recurrence in these patients.

Methods: MEDLINE (PubMed), EMBASE and Cochrane databases were searched until January 2024. Inclusion criteria encompassed patients undergoing pleurodesis through video-assisted thoracoscopic surgery (VATS) for PSP if chest tube management was clearly described to discriminate between early and late tube removal protocols, and recurrence rate with a postoperative follow-up period of at least six months was reported. The primary outcome was recurrence rate, with secondary outcomes including postoperative length of stay (LOS), prolonged air leakage (PAL) and chest tube duration. Subgroup analysis contained type of pleurodesis. The quality of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation method.

Results: Thirty-six studies comprising 6,166 patients were included, lacking direct comparative studies on early versus late chest tube removal. Due to loss to follow-up, 6,063 patients were analysed regarding recurrence rate, resulting in 4.49% [95% confidence interval (CI): 3.33-6.03%; I²=65.6%] after late removal and 7.61% (95% CI: 5.44-10.57%; I²=8.2%) after early removal (P=0.02). Among the secondary outcomes only chest tube duration was significantly different between early and late removal [2.50 (95% CI: 2.31-2.71) versus 3.42 (95% CI: 3.08-3.81) days, P<0.001]. Subgroup analysis revealed the most pronounced difference in recurrence following pleurectomy as type of pleurodesis (P=0.003). The quality of evidence was considered low.

Conclusions: Although no direct comparative studies were retrieved, the best available evidence suggests that early chest tube removal may be associated with a slightly higher recurrence rate after surgical pleurodesis for pneumothorax. High-quality evidence is needed before implementing early removal.