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International guidelines do not recommend surgery for the first episode of primary spontaneous pneumothorax (PSP), except in cases of persistent air leak, hemopneumothorax, bilateral pneumothorax, or occupations at risk. However, these recommendations have been challenged because of a significant reduction in the recurrence rate in emerging studies. We evaluated the rationale of recommendations by systematically reviewing RCTs and observational studies by using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system. We searched articles in PubMed, EMBASE, and Cochrane databases up to August 15, 2020. The primary outcomes were the recurrence rate and complication rate. The secondary outcomes were hospital stay and drainage duration. Nine eligible studies with 1121 patients were retrieved and analyzed. The recurrence rate was lower in the VATS than in conservative treatment with moderate evidence (OR 0.13, 95% CI 0.09 to 0.19,  P  < 0.001, I 2  = 0%). We did not find significant differences in complication rate (Peto OR 1.17, 95% CI 0.33 to 4.12,  P  = 0.80), hospital stay duration (MD − 0.48 days, 95% CI − 2.84 to 1.87,  P  = 0.69, very low evidence), and in drainage duration (MD − 3.99 days, 95% CI − 9.06 to 1.08,  P  = 0.12, very low evidence) between the two groups. Our results would suggest VATS treatment as a weak recommendation for patients with the first episode of PSP, based on our systematic review of the current evidence by using the GRADE system, indicating that different treatments will be appropriate for different patients and that patients’ values and preferences should be incorporated through shared decision making.  Trial REGISTRY: PROSPERO; No.: CRD42020162267.

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Recommendation for management of patients with their first episode of primary spontaneous pneumothorax, using video-assisted thoracoscopic surgery or conservative treatment