Chest
Volume 144, Issue 6, December 2013, Pages 1857-1867
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Original Research
Pulmonary Procedures
Diagnostic Accuracy and Safety of Semirigid Thoracoscopy in Exudative Pleural Effusions: A Meta-analysis

https://doi.org/10.1378/chest.13-1187Get rights and content

Background

The usefulness of semirigid thoracoscopy in undiagnosed exudative pleural effusions (EPEs) has been variably reported in different studies. Herein, we perform a systematic review and meta-analysis to estimate the overall diagnostic yield and safety of semirigid thoracoscopy in EPE.

Methods

We searched the PubMed and EMBASE databases for studies reporting the outcomes of semirigid thoracoscopy in EPE. The quality of studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. The yield of semirigid thoracoscopy was analyzed by calculating the sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic OR (DOR) for each study and pooling the study results using a random effects model. Heterogeneity and publication bias were assessed for individual outcomes. Sensitivity analysis was performed to explore the potential causes of heterogeneity.

Results

Our search yielded 17 studies (755 patients with undiagnosed EPE). The sensitivity, specificity, PLR, NLR, and DOR of semirigid thoracoscopy was 91%, 100%, 4.92, 0.08, and 102.28, respectively. The area under the curve for the summary receiver operating characteristic curve was 0.93. There were negligible complications and no mortality. There was evidence of heterogeneity, which significantly decreased on sensitivity analysis after exclusion of smaller (< 25 participants) studies. There was no evidence of publication bias.

Conclusions

Semirigid thoracoscopy is an efficacious and safe procedure in diagnosis of EPE. Because of the small sample size, larger well-designed trials are required to confirm the results of this study. There is also a need for head-to-head comparison of semirigid and rigid thoracoscopy.

Section snippets

Search Strategy

We first searched the PubMed and EMBASE databases for any systematic review reporting the diagnostic efficacy of semirigid thoracoscopy in undiagnosed EPE. One systematic review published in 2010 comprising five studies and 154 patients was found.19 All the authors then independently searched the PubMed (1995 to February 2013) and EMBASE (1995 to February 2013) databases for studies describing the diagnostic value of semirigid thoracoscopy using the following search terms: (1) (thoracoscopy[ti]

Characteristics and Quality of the Studies

Our initial database search retrieved a total of 4,389 citations (Fig 1), of which 17 studies (755 patients with undiagnosed EPEs) finally met our inclusion criteria.17, 18, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46 One study was excluded because of the possibility of overlap of patients.47 The studies have been reported from across the globe, both from the developed and the developing world. Of these, 10 studies were prospective and seven retrospective (Table 1). The criteria

Discussion

The results of this meta-analysis (17 studies, 755 patients with undiagnosed pleural effusions) suggest that semirigid thoracoscopy has good sensitivity (91%) and excellent specificity (100%) in diagnosis of EPEs of undetermined cause. The PLR was 4.92, and the NLR was 0.08. Likelihood ratios > 10 and < 0.1 are considered as strong indicators to rule in or rule out a diagnosis, respectively.48 In clinical practice, 10% of the patients can be potentially missed with semirigid thoracoscopy.

Acknowledgments

Author contributions: Dr Agarwal is guarantor of the paper, taking responsibility for the integrity of the work as a whole, from inception to published article.

Dr Agarwal: contributed to conceiving the article, systematic review, meta-analysis, and drafting and revising the manuscript.

Dr Aggarwal: contributed to the systematic review and drafting and revising the manuscript.

Dr Gupta: contributed to the systematic review and drafting and revising the manuscript.

Financial/nonfinancial disclosures:

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    Funding/Support: The authors have reported to CHEST that no funding was received for this study.

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