Safety in Rib Surgery: A Meta-analysis and Systematic Review

We read with interest the recent article, “Safety in rib surgery: a meta-analysis and systematic review,” but identified several methodological and reporting issues that, in our view, call the validity of its conclusions into question.¹

First, the literature search reported in Figure 1 is inappropriately narrow.¹ The authors state that their multidatabase search (PubMed, Scopus, Embase, Cochrane, Google Scholar) yielded only 17 initial studies before deduplication. This appears inconsistent with typical reproducibility expectations. For example, in PubMed alone, the term “cosmetic thoracic procedures” returns 1493 results and “aesthetic rib surgery” returns 417 results when entered individually. Even before deduplication, this yield should have been orders of magnitude higher than reported. Such a discrepancy strongly suggests an incomplete or improperly executed search strategy, raising concerns that a substantial portion of the relevant literature was not screened for inclusion.

Second, the authors applied the Cochrane risk-of-bias 2 (RoB 2) tool, intended exclusively for randomized controlled trials, to evaluate studies that were nonrandomized observational designs, such as retrospective studies and case series. More troubling, for Domain 1 (“Bias arising from the randomization process”), the authors rated all studies as “low risk,” despite none of their included studies used randomization of any kind.¹ According to the ROB 2 guidance, this domain is not applicable when no randomization has occurred.² Scoring it as “low risk” in such cases is a likely misapplication of the bias evaluation and undermines the credibility of the article’s risk-of-bias assessment.

Finally, Table 1 contains entries under “study name” that have no apparent basis in the scientific literature, including “Executioner and cabbage,” “Apple and cabbage,” and “Oñate and cabbage.”¹ These seem to be placeholders, mistranslations, or other uncorrected errors. Their presence suggests a lack of basic quality control in manuscript preparation and suggests that a careful review of the accuracy of the extracted data may be warranted.

Taken together, these issues suggest that the review’s evidence base is incomplete, its quality assessment is methodologically flawed, and its data presentation contains significant errors. In the nature of collegial dialogue and academic rigor, we respectfully encourage the authors and editors to revisit these points to ensure that the conclusions drawn are based on a comprehensive, methodologically sound, and accurately reported synthesis of the literature.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.