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It argues that pooled effects suggesting no clear difference in “failure” should be interpreted cautiously due to limited representation of high-risk phenotypes, heterogeneity of the composite failure endpoint, and the extremes-only tube-size contrast. The letter highlights dependence of trial sequential analysis conclusions on prespecified assumptions and recommends explicit justification and sensitivity analyses to improve transparency, prevent overgeneralization, and inform pragmatic multicenter trial design with patient-centered 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\n[https://doi.org/10.1186/s13017-025-00669-5](https://doi.org/10.1186/s13017-025-00669-5)  \nWorld Journal of Emergency Surgery  \nCORRESPONDENCE Open Access  \nRe: Small versus large bore chest  \ntube in traumatic hemothorax, hemopneumothorax, and pneumothorax—external validity, endpoint heterogeneity, and trial sequential analysis assumptions  \nAuthor:  \nSithdharthan Ravikumar 1*  \nAbstract  \nBackground Granieri and colleagues compared small-caliber chest drains (14 Ch or smaller) with large-bore chest tubes (28 Ch or larger) for traumatic hemothorax, hemopneumothorax, and pneumothorax and combined conventional meta-analysis with trial sequential analysis. Main points: While the pooled effect estimate suggested no clear difference in treatment failure, clinical translation requires caution. First, the randomized trials largely representselected, stable thoracic trauma rather than high-risk phenotypes (for example, massive hemothorax, ventilated patients, or severe polytrauma) . Second, the primary endpoint (“failure”) groups reinterventions that vary in clinical impact and are sensitive to local imaging and escalation thresholds (for example, second drain versus video-assisted surgery) . Third, trial sequential analysis conclusions depend strongly on prespecified assumptions (baseline event rate and the smallest clinically important effect), which should be explicitly justified and, where possible, explored insensitivity analyses.  \nConclusion These clarifications may reduce overgeneralization, better align conclusions with the included trial populations, and inform pragmatic multicenter trial design with standardized protocol s and patient-centered outcomes.  \nKeywords Trauma, Hemothorax, Pneumothorax, Tube thoracostomy, Pigtail catheter, Trial sequential analysis  \n*Correspondence: Sithdharthan Ravikumar [sithdharthan94@gmail.com](sithdharthan94@gmail.com)  \n1Department of General Surgery, George Eliot Hospital NHS Trust, College Street, Nuneaton, Warwickshire CV10 7DJ, UK  \n© The Author(s) 2026. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit [http://creati](http://creati)[vecommons.org/l](vecommons.org/l)icenses/by-nc-nd/4.0/.  \nRavikumar World Journal of Emergency Surgery (2026) 21:2  \nMain text  \nDear Editors  \nI read with interest the meta-analysis by Granieri et al. comparing small-caliber chest drains (SCTs, ≤ 14 Ch) with large-bore chest tubes (LCTs, ≥ 28 Ch) for traumatic hemothorax, hemopneumothorax, and pneumothorax.1 The restriction to randomized trials and the use of trial sequential analysis (TSA) are welcome strengths that help address the risk of random error in a sparse evidence base.1 This correspondence aims to clarify methodological considerations that may assist clinicians in interpreting the trial sequential analysis and help guide future trial design.  \nExternal validity: applicability is mainly to selected, stable injuries  \nThe included randomized trials largely enrolled hemodynamically stable patients with uncomplicated thoracic injuries","cbCaiicGORMEWRQx","https://ap.wps.com/l/cbCaiicGORMEWRQx","pdf",539468,"English","# Abstract\n## External validity: applicability is mainly to selected, stable injuries\n## Endpoint heterogeneity: “failure” aggregates interventions of unequal clinical weight\n## Tube-size spectrum: extremes comparison does not address mid-range practice\n## Trial sequential analysis assumptions: transparency and sensitivity ranges would strengthen conclusions\n## Clinical implications","[{\"question\":\"What is the main purpose of this correspondence?\",\"answer\":\"It clarifies methodological considerations to help clinicians interpret the trial sequential analysis and to guide future trial design.\"},{\"question\":\"Why does the correspondence caution against bedside overgeneralization?\",\"answer\":\"Included randomized trials largely reflect stable, uncomplicated thoracic injuries, while high-risk phenotypes such as massive hemothorax, ongoing bleeding, mechanically ventilated patients, and severe polytrauma appear underrepresented or inconsistently reported.\"},{\"question\":\"How does endpoint heterogeneity affect interpretation of “failure”?\",\"answer\":\"“Treatment failure” combines different downstream reinterventions (e.g., second drain, fibrinolysis, image-guided drainage, video-assisted thoracoscopy, thoracotomy) whose clinical impact varies and depends on local protocols and escalation thresholds.\"}]","Re: Small versus large bore chest tube in traumatic hemothorax, hemopneumothorax, and pneumothorax - external validity, endpoint heterogeneity, and trial sequential analysis assumptions - clarify methodological considerations | PDF",1790749675]