The diminishing role of surgery in pleural disease

Pleural disease is common. Traditionally, many patients were subjected to surgery for diagnosis and treatment. Most pleural surgical procedures have not been subjected to high-quality clinical appraisal and their use is based on anecdotal series with selection bias. The evidence (or the lack) of benefits of surgery in common pleural conditions is reviewed.

Recent studies do not support the routine therapeutic use of surgery in patients with malignant pleural effusions, empyema or mesothelioma. Four randomized studies have failed to show significant benefits of thoracoscopic poudrage over bedside pleurodesis. Surgery as first-line therapy for empyema was studied in four randomized studies with mixed results and no consistent benefits. Cumulative evidence suggests that radical surgery in mesothelioma, especially extrapleural pneumonectomy, is not justified. Advances in imaging modalities and histopathological tools have minimized the need for surgery in the workup of pleural effusions. Complications associated with surgery are increasingly recognized.

Surgery has associated perioperative risks and costs, and residual pain is not uncommon. Many conventional pleural surgeries have not been assessed in randomized studies. Pulmonologists should be aware of the evidence that supports surgical interventions, or the lack of it, in order to make informed clinical decisions and optimize patient care.