title: Thoracoscopic procedures in pediatric surgery: what is the evidence?
abstract: BACKGROUND
  Video-assisted thoracoscopic surgery (VATS) has gained enormous acceptance among pediatric surgeons. However, most studies on advantages of VATS do not reach a high level of evidence. According to a recent classification of the Oxford Centre for Evidence-Based Medicine (CEBM), studies can be classified into Levels 1 to 5 in order of descending quality. We aimed to identify comparative studies investigating VATS versus open procedures in pediatric surgery and to classify publications according to the CEBM criteria.
  
  
  METHODS
  Systematic review of comparative studies were identified using PubMed. Only studies published in English, comparing pediatric VATS with the corresponding open operation were included. End points were advantages and disadvantages of VATS as compared with the open procedure. Levels of evidence were determined using the recent CEBM criteria.
  
  
  RESULTS
  A total of 3 meta-analysis (MA) and 18 retrospective comparative studies (RCS) investigating 5 different VATS procedures (repair of congenital diaphragmatic hernia [CDH], repair of esophageal atresia/tracheoesophageal fistula (EA/TEF), lung resection, treatment of pneumothorax, and resection of neuroblastoma) were included in this study. No studies of CEBM Level 1 or Level 2 were identified. All studies were classified as CEBM Level 3. The advantages of VATS were less postoperative pain (CDH repair, EA/TEF repair, and pneumothorax repair), shorter hospital stay (CDH repair, EA/TEF repair, lung resection, and pneumothorax), shorter time of ventilation and lower Pco 2 (CDH repair), shorter duration of chest drain (lung resection), and less blood loss (resection of neuroblastoma). However, disadvantages such as higher recurrence rates (CDH repair), higher Pco 2 (EA/TEF repair), and longer operative times (CDH and EA/TEF repair) were also identified.
  
  
  CONCLUSIONS
  Only RCS on pediatric VATS are available. Therefore, the best available evidence is Level 3. Randomized controlled trials comparing VATS and the corresponding open procedure are mandatory to obtain the highest possible evidence.
authors.affiliation: Center of Pediatric Surgery, Hannover Medical School and Bult Children's Hospital, Hannover, Germany.
authors.forename: Carmen
authors.initials: C
authors.lastname: Dingemann
authors.affiliation: Center of Pediatric Surgery, Hannover Medical School and Bult Children's Hospital, Hannover, Germany.
authors.forename: Benno
authors.initials: B
authors.lastname: Ure
authors.affiliation: Center of Pediatric Surgery, Hannover Medical School and Bult Children's Hospital, Hannover, Germany.
authors.forename: Jens
authors.initials: J
authors.lastname: Dingemann
mesh_terms: D004933:Esophageal Atresia / Q000601:surgery; D019317:Evidence-Based Medicine; D006548:Hernia, Diaphragmatic / Q000601:surgery; D065630:Hernias, Diaphragmatic, Congenital; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D009447:Neuroblastoma / Q000601:surgery; D011013:Pneumonectomy; D011030:Pneumothorax / Q000601:surgery; D011183:Postoperative Complications / Q000517:prevention & control; D016032:Randomized Controlled Trials as Topic; D055502:Secondary Prevention; D013899:Thoracic Neoplasms / Q000601:surgery; D020775:Thoracic Surgery, Video-Assisted / Q000379:methods*; D014138:Tracheoesophageal Fistula / Q000601:surgery