Effects of Different Treatment Regimens on Primary Spontaneous Pneumothorax: A Systematic Review and Network Meta-Analysis

Abstract Background: The best treatment strategy for primary spontaneous pneumothorax is controversial and varies widely in practice, so we conducted a systematic review and network meta-analysis to clarify which treatment is optimal. Methods: Literatures were searched from relevant databases till 24 August 2021. A Bayesian network meta-analysis was conducted to compare the outcomes of various treatment regimens with the following endpoints: recurrence rate; postoperative chest tube duration; postoperative air leakage duration; length of hospital stay and rate of complications. The surface under the cumulative ranking curve was used to rank the treatments. Results: 7210 patients of 20 randomized controlled trials and 17 cohort studies were included. In terms of recurrence reduction, there was no significant difference between any pairs of conservative treatment, manual aspiration and chest tube drainage. Surgical methods had a significantly lower recurrence rate compared to manual aspiration and chest tube drainage. Besides, bullectomy combined with additional procedures such as chemical pleurodesis, mechanical pleuodesis or staple line coverage can reduced the recurrence rate of PSP compared to bullectomy along, but none of them were statistically significant. In terms of reducing postoperative chest tube duration, “bullectomy with tubular Neoveil” outperformed “bullectomy + pleural abrasion” (MD, 95%CI: -2.5[-4.63, -0.35]) and “bullectomy + apical pleurectomy” (MD, 95%CI: -2.72[-5.16, -0.27]).Conclusions: Surgical methods were superior to manual aspiration, chest tube drainage and conservative treatment in terms of recurrence reduction. There was no significant difference between manual aspiration and chest tube drainage in reducing recurrence rate, but manual aspiration was linked to a shorter hospital stay and a lower rate of complications. Conservative treatment is an acceptable alternative to chest tube drainage or manual aspiration due to similar recurrence rates but lower incidence of complications. Among surgical methods, chemical pleuodesis is more effective than mechanical pleuodesis and staple line coverage among the additional procedures based on bullectomy. Moreover, bullectomy with tubular Neoveil was superior to bullectomy along. However, more randomized controlled trials are needed to confirm these findings and raise the level of evidence.Registration: The protocol was registered with PROSPERO (CRD42021236922).