Is open thoracotomy still a good treatment option for the management of empyema in children?

Open pleural decortication for the late stage empyema thoracis in children: a retrospective observational study from a tertiary hospital of eastern Nepal

The management of late-stage empyema thoracis requires surgical intervention. We performed a retrospective descriptive analysis of open pleural decortication for late stage empyema thoracis in 55 children (age ≤ 15 years; median age = 6 years; age range = 1-15 years; 40 [72.7%] boys) over 42 months. The median time to thoracotomy from the onset of symptoms was 24 days, and the median duration of hospital stay before and after surgery was 15 and 4 days, respectively. Three (5.5%) patients had necrotising pneumonia, requiring debridement; 4 (7.3%) patients had superficial surgical site infection; 12 (21.8%) patients had perioperative pus culture positive for bacteria; and 3 (5.5%) patients had tubercular aetiology. There was no operative mortality. At median follow-up of 18 months, all patients are in good general health. Open pleural decortication leads to rapid resolution of symptoms and reduces hospital stay in paediatric late-stage empyema thoracis.

Pediatric empyema thoracis: roles and outcomes of surgery in advanced disease

Aim

Empyema thoracis has become increasingly common in the pediatric population. Antibiotics and thoracostomy have been the cornerstones of management of stage 1 empyema, whereas management of stage 2 and 3 empyema remains controversial. Surgical intervention is perceived to be associated with high morbidity and protracted recovery. We aimed to review the role and outcome of surgical decortication, and provide data for comparison with other treatment modalities.

Methods

The medical records and clinical outcomes of 30 children (median age 5.2 years) with stage 2 or 3 empyema, who underwent surgical decortication from September 2017 to September 2019, were reviewed.

Results

Most children were referred for decortication by day 8.8 ± 4 of admission, and the median time from referral to surgery was 2.2 ± 2 days. All patients had tube thoracostomy, and 5 (17%) underwent fibrinolysis prior to surgery. Twenty-one (70%) patients required pediatric intensive care unit admission preoperatively. Postoperatively, most patients were extubated on day 2.5 (range 1–4 days), with chest tubes removed on day 3.8 (range 1–7 days). Most were discharge by day 6.2 (range 4–10 days). Postoperative air leak occurred in one (3%) patient. There was no mortality or reoperation.

Conclusion

Surgical decortication remains an excellent modality for managing stage 2 and 3 pediatric empyema. The procedure has a low morbidity and provides rapid resolution of symptoms with good clinical outcomes if performed promptly. Delayed referral may result in a more protracted clinical course.

Severe necrotizing pneumonia complicated by empyema in a neonate

Necrotizing pneumonia is a severe complication of pneumonia, characterized by local destruction of lung tissue with development of multiple small cavities (abscesses) and may be associated with empyema. Empyema is an unusual complication in neonates with limited data reported. We present a healthy term neonate with late-onset sepsis caused by Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia due to severe necrotizing pneumonia associated with advanced stage empyema. To the best of our knowledge this is the youngest reported patient with multifocal lung abscesses associated with stage 2 empyema treated successfully without surgical intervention.

Thoracoscopy in pediatrics: Surgical perspectives

Thoracoscopic surgery and other minimally invasive approaches in children achieved marked advancement and expanded to include several disciplines in the last decade. The new armamentarium of the minimally invasive surgery including the smaller instruments and better magnification led to the application of this technology in the small infants and neonates. Currently, thoracoscopy is considered the preferred surgical approach for various conditions in neonates and infants over the standard thoracotomy, and thoracoscopic training is included in the surgical training curriculum for the residents in many institutes worldwide. Children are different from adults, and technique modifications are required when using thoracoscopy in children. Thoracoscopy showed satisfactory results in several operations including pulmonary resections, mediastinal tumors biopsies or resections, repair of the diaphragmatic hernias, decortication, and tracheoesophageal fistula. This review aims to address the unique aspects of thoracoscopic surgery in children, identify its potential technical and anatomical challenges, and the proposed solutions. A literature search for latest and relevant publications was done using the keywords (thoracoscopy; pediatric; lung biopsy; decortication; lobectomy; mediastinum; esophagus; and diaphragmatic hernia).

Analgesic management after thoracotomy for decortication in children: a retrospective audit of 83 children managed with a paravertebral infusion-based regime

BACKGROUND

It is important that postoperative analgesic management after thoracotomy is very effective in order to optimize postoperative recovery. A regional technique such as an epidural or a paravertebral catheter with an infusion of local anesthetic may be supplemented with systemically administered analgesic drugs in order to achieve satisfactory analgesia.

OBJECTIVE

The objective of this observational study was to evaluate whether a paravertebral infusion of local anesthetic delivered via a surgically placed catheter together with systemic analgesics is associated with low pain scores and satisfactory analgesia after thoracotomy for decortication in children.

METHODS

We performed a retrospective analysis of the notes and charts of 83 children admitted with empyema thoracis and managed with thoracotomy and decortication. We collected data on the doses of analgesic drugs (morphine, paracetamol, and ibuprofen) and details of paravertebral infusions, together with postoperative pain scores for the first 48 h after surgery, or earlier if the paravertebral infusion was stopped within 48 h of surgery. Poor quality analgesia was defined as a score of 7 or more on the Visual Analog/Smiley Faces Scale ('VAS/SF').

RESULTS

A total of 81 children were ASA 1 status and two were ASA 3 status. Analgesia comprised intravenous morphine at a mean dose of 20 μg·kg(-1) ·h(-1) , together with oral paracetamol (62.5 mg·kg(-1) /24 h) and ibuprofen (14.2 mg·kg(-1) /24 h). The mean paravertebral bupivacaine dose was 0.29 mg·kg(-1) ·h(-1) . Sixty-four patients (77.1%) had good quality analgesia, 17 (20.5%) patients had moderate quality analgesia, and only two patients (2.4%) had poor quality analgesia.

CONCLUSION

Analgesic outcomes with this regimen appear to be very satisfactory. It compares favorably with an epidural-based regimen.

Outcome of Pediatric Empyema Thoracis Managed by Tube Thoracostomy

The proper management of empyema thoracis in children continues to be a source of debate. This study assessed the clinical profile and outcome of patients managed by tube thoracostomy. Chart review was performed in 31 patients managed from January 1989 to December 2003. Outcome measures were duration and outcome of thoracostomy, number of days to radiologic lung re-expansion, length of hospitalization, and microbiologic flora involved. The mean age was 9 years (male/female, 2:1) and the most commonly affected group were those aged 1 year and below. Staphylococcus aureus was the most frequent infecting organism. A few (6%) achieved lung re-expansion 1 week postoperatively, but 64% did not achieve full lung re-expansion even after 3 weeks. Most (71%) of the thoracostomies were converted to open drainage. Half (52%) of the patients were hospitalized for at least 5 weeks. There were 3 recurrences and 3 deaths, 2 of which were most likely associated with empyema. Empyema managed by tube thoracostomy alone showed evidence of delayed lung re-expansion, prolonged drainage and hospitalization, and unfavorable outcome.

An Approach to the Management of Pleural Empyema with Early Video-assisted Thoracoscopic Surgery and Early Transition to Oral Antibiotic Therapy

Practice variation exists in the management of children with bacterial pneumonia complicated by empyema. The success of video-assisted thoracoscopic surgery (VATS) versus chest tube insertion for drainage and fibrinolysis may be dependent on the stage of disease. There is little published experience with early transition to oral (PO) antibiotics, and many children are treated with intravenous (IV) antibiotics at home. To describe a cohort of children with pneumonia and empyema in a primarily rural state managed with early VATS and transition to PO antibiotics. This was a retrospective medical record review of children managed by the pediatric infectious diseases and surgery services at Kosair Children's Hospital from 2008 through 2012. Sixty-one children met inclusion criteria. The majority underwent VATS on the first or second hospital day. No organism was identified in 67 per cent of cases. All patients received IVantibiotics at admission and all were discharged on PO antibiotics. The median time to transition was five days (interquartile range [IQR], 4–6), and the median duration of PO therapy was 16 days (IQR, 14–21). Ninety-eight per cent did not require further IV therapy. There were no deaths and clinical outcomes were good. In conclusion, children with pneumonia and empyema can be managed effectively with early VATS and early transition from IV to PO antibiotic therapy.

Current Surgical Management of Empyema Thoracis in Children: A Single-center Experience

Empyema is a morbid complication of pneumonia in children, whose gold standard of surgical treatment technique remains undefined. Historically, treatment consisted of open thoracotomy with decortication. We evaluate the effectiveness and safety of video-assisted thoracoscopic surgery (VATS) as a surgical treatment in for empyema thoracis in a pediatric population at a single institution from 2005 to 2013. After receiving Institutional Review Board approval, we performed a retrospective chart review of children surgically treated for empyema as a complication of pneumonia from 2005 to 2013. Charts were reviewed for the type of procedure performed (VATS or open thoracotomy), comorbid conditions, preoperative status, operative outcomes, and postoperative status. A total of 112 pediatric patients were treated surgically for empyema. Surgical treatment consisted of VATS in all cases; no open thoracotomy procedures were performed. The success rate of VATS in our study was 96.4 per cent. Mean total length of stay was found to be 8.8 days, whereas postoperative length of stay was 6.3 days. Mean postoperative chest tube duration was 3.4 days. Perioperative complication rate was 11.6 per cent, with respiratory failure being the most common complication. The data from our study demonstrate that the exclusive use of VATS in children for the surgical management of all stages of empyema was safe and produced results with high efficacy. We consider VATS to be the new gold standard for surgical drainage of empyema.

Indicators for surgical intervention in thoracic empyema in children

OBJECTIVES

To determine predictors for surgical intervention of thoracic empyema in children, and its associated morbidity.

METHODS

We conducted a retrospective review of medical records of children with empyema thoracis admitted in the Maternity and Children Hospital, Al Madinah Al Munawwarah, Saudi Arabia between January 2007 and January 2012. The data extracted included: socio-demographic data, clinical data, method of treatment, and follow up data. According to the introduced therapeutic methods, a total of 62 patients were divided into 2 groups; patients treated with chest tube (CT) insertion (51 cases), and 11 cases that required thoracotomy (TH); groups were compared to determine predictors for thoracotomy.

RESULTS

Of 62 patients, 37 were females and 25 were males. In terms of age, side of lesion, presence of cough, or dyspnea, both groups were homogenous. Both groups had significant differences for duration of complaint (TH and CT) (13.5±6.5 days versus 10±3.6, p=0.005), presence of fever (90.2% versus 36.4%, p less than 0.001), history of recurrent chest infections (90.9% versus 37.3%, p=0.001), and radiological findings. However, it was not evident that any of these variables influenced treatment decision except absence of fever, which was significantly less in patients treated with thoracotomy.

CONCLUSION

No specific indicator was found to increase expectancy for surgical intervention as a treatment choice, except the absence of fever, which may reflect the delayed referral and prolonged use of antibiotics and cannot be interpreted truly without caution as an indicator for surgical intervention.

Current evidence for the management of paediatric parapneumonic effusions

BACKGROUND

Parapneumonic effusions (PPE) and empyema, secondary to bacterial pneumonia, are relatively uncommon but their prevalence is increasing lately. Even if their prognosis is generally good, they may still cause significant morbidity. The traditional treatment of PPE has been intravenous antibiotics and, when necessary, chest tube drainage. Open thoracotomy with decortication has usually been applied in case of failure of the traditional approach. Lately, the use of fibrinolysis and/or video-assisted thoracoscopic surgery (VATS) are utilized in the management of PPE; however, there is still little consensus on the most effective primary treatment.

SCOPE

In this article our goal was to summarize, based on up-to-date evidence, all the management options for PPE available to physicians and weigh the benefits and risks of the most popular ones, in an effort to figure out which one is superior as a first-line approach in children.

FINDINGS

A literature search of randomized and retrospective studies that pinpoint methods of evaluation and treatment of PPE was carried out in Medline and Scopus databases. Chest X-ray, ultrasound as well as microbiology and biochemical characteristics of the pleural fluid will facilitate decision-making. Small uncomplicated effusions resolve with antibiotics alone, larger ones require small-bore chest tube drainage and in case of complicated loculated PPE, fibrinolysis or VATS should be considered. Both methods promote faster drainage, reduce hospital stay and obviate the need for further interventions when used as first-line approach. However, primary treatment with VATS is not advised by the majority of studies as a first choice intervention, unless medical treatment has failed.

CONCLUSION

The main steps in treatment are diagnostic thoracocentesis and imaging, small percutaneous drainage, and considering fibrinolysis in complicated PPE. In case of failure, VATS should be the surgical method to be applied.

Effects of blood conservation on the incidence of anemia and transfusions in pediatric parapneumonic effusion: a hospitalist perspective

BACKGROUND

Children with pneumonia may develop parapneumonic effusion (PNE). The associated inflammatory process and nutritional compromise can blunt erythropoesis. Traditional treatment for these children with PNE includes repeated phlebotomy and surgical intervention, resulting in ongoing blood losses. Blood transfusions used to treat acquired anemia are associated with multiple complications.

OBJECTIVES

This study evaluated the effect of hospitalists' implementation of blood conservation guidelines (BCG) on the incidence of anemia and transfusion requirements in children with PNE.

DESIGN

Retrospective cohort study of hospitalized children with PNE.

SETTINGS

University affiliated Children's Hospital.

PATIENTS

Children who were admitted to the hospital with PNE and managed using BCG (Group I) were compared to simultaneous no intervention group (S) and historical no intervention group (H). Group (I) and (S) were admitted from year 2000 to 2004 and the Group (H) were admitted from year 1997 to 1999.

MEASUREMENTS

Phlebotomy frequency and volume, measured hemoglobin (Hgb) levels, and the need for red blood transfusions.

RESULTS

Children in the BCG group (n = 24) compared to simultaneous no intervention group (n = 28) and historical no intervention group (n = 29) had lesser phlebotomy volumes (14 ± 8, 18 ± 14 and 69 ± 66 mL; P = 0.001), trend toward lesser Hgb drop (1.7 ± 1.4, 2.1 ± 1.2 and 2 ± 1.4 gm%; P ≤ 0.37), and lesser incidence of transfusion (8%, 18% and 31%; P = 0.11). Transfused children were younger (3.5 ± vs. 6.4 ± 4 years; P = 0.001) and had lower initial Hgb (9.9 ± 1 vs. 11.4 ± 1 gm%; P = 0.001), more phlebotomy (5.9 ± 7 vs. 1.1 ± 1 mL/kg., P = 0.001), longer hospitalization (18.7 ± 5 vs. 11.1 ± days; P = 0.001), and slightly higher (pediatric risk of mortality [PRISM]) scores (3.4 ± 5.7 vs. 1.6 ± 2.7; P = 0.25).

CONCLUSION

Implementing BCG lowers phlebotomy losses and the need for transfusion.

Thoracic empyema, application of video-assisted thoracic surgery and its current management

PURPOSE OF REVIEW

Pneumonia in children is frequently complicated by pleural effusions, which rarely progress to empyema. Appropriate clinical management depends on correctly diagnosing the stage of the disease process. Recently, increasing use of video-assisted thoracic debridement has altered the traditional management of pleural effusions and empyema in children, resulting in decreasing reliance on thoracentesis and earlier surgical intervention.

RECENT FINDINGS

We review the current literature supporting the clinical indications for video-assisted thoracic debridement compared with traditional management, including the use of thoracentesis, chest tube placement, fibrinolytic therapy and open thoracotomy in children with empyema. Recent studies support the early application of video-assisted thoracic debridement in children with empyema compared with traditional therapy, as it decreases the number of procedures and studies performed and the duration of chest tube drainage and is associated with less pain and shorter recovery period than open thoracotomy.

SUMMARY

We propose a clinical algorithm supporting the early use of video-assisted thoracic debridement in the management of empyema in children.

Spirometric changes after pleural decortication in young adults

BACKGROUND

The collection of pleural fluid and thickened pleura restrict the movement and expansion of lung. The main treatment strategy is lung decortication for the thickened pleura. The aim of this study was to investigate lung functions before and after pleural decortication in young adults.

METHODS

A total of 63 patients with thickened pleura were retrospectively evaluated. Before the operation, patients with tuberculosis (n = 36) were treated with anti-tuberculosis therapy for 3-6 months. Patients with non-tuberculosis causes (n = 27) had been treated with broad-spectrum antibiotics. Forced expiratory volume in 1 s (FEV1, %), forced vital capacity (%) and vital capacity (litre) were measured before and after decortication.

RESULTS

Spirometric parameters FEV1 (68.1 +/- 16.7 vs 71.01 +/- 14.4), forced vital capacity (67.6 +/- 16.4 vs 71.3 +/- 14.4) and vital capacity (2.6 +/- 0.6 vs 2.8 +/- 0.7) significantly improved after the operation (P +/- 0.01). Spirometric changes were not significantly different between tuberculosis and non-tuberculosis groups.

CONCLUSION

Pleural decortication may improve the lung restoration in patients with thickened pleura and also improve lung functions significantly in young adults.

Pleurésies purulentes communautaires de l'enfant. Où en sommes-nous?

Community-acquired pleural infection is a life-threatening complication of pneumonia in children. It seems to be more prevalent actually. This pathology is associated with an high morbidity and frequently requires prolonged hospitalization and invasives procedures. However, there is no consensus on its management in pediatrics, especially because of the lack of trials. To improve the quality of the future studies and to compare the series, a child-adapted classification is required. To date, in attempt of evidence, chest drainage or thoracocentesis-thoracoscopy are questionable. For treatment, high regimens of synergic and intravenously-delivered antibiotics seem to be the better choice.

Thoracoscopy in pediatric pleural empyema: a prospective study of prognostic factors

PURPOSE

The indications for thoracoscopy remain imprecise in cases of pleural empyema. This study aimed to identify preoperative prognostic factors to help in the surgical decision.

METHODS

From 1996 to 2004, 50 children with parapneumonic pleural empyema underwent thoracoscopy either as the initial procedure (n = 26) or after failure of medical treatment (n = 24). Using multivariate analysis, we tested the prognostic value of clinical and bacteriological data, the ultrasonographic staging of empyema, and the delay before surgery. Outcome measures were technical difficulties, postoperative complications, time to apyrexia, duration of drainage, and length of hospitalization.

RESULTS

The clinical and bacterial data did not significantly predict the postoperative course. Echogenicity and the presence of pleural loculations at ultrasonography were not independent significant prognostic factors. A delay between diagnosis and surgery of more than 4 days was significantly correlated (P < .05) with more frequent surgical difficulties, longer operative time, more postoperative fever, longer drainage time, longer hospitalization, and more postoperative complications, such as bronchopleural fistula, empyema relapse, and persistent atelectasia.

CONCLUSION

The main prognostic factor for thoracoscopic treatment of pleural empyema is the interval between diagnosis and surgery. A 4-day limit, corresponding to the natural process of empyema organization, is significant. The assessment of loculations by ultrasonography alone is not sufficient to predict the postoperative course.

Therapy of parapneumonic effusions in children: video-assisted thoracoscopic surgery versus conventional thoracostomy drainage

OBJECTIVE

Controversy surrounds the optimal treatment of parapneumonic effusions. This trial of pediatric patients with community-acquired pneumonia and associated parapneumonic processes compared primary video-assisted thoracoscopic surgery with conventional thoracostomy drainage.

DESIGN

A prospective, randomized trial was conducted at DeVos Children's Hospital (Grand Rapids, MI) between November 2003 and May 2005. All of the patients under 18 years of age with large parapneumonic effusions were approached for enrollment in the study. After enrollment, each patient was randomly assigned to receive either video-assisted thoracoscopic surgery or thoracostomy tube drainage of the effusion. Subsequent therapies (fibrinolysis, imaging, and further drainage procedures) were similar for each group per protocol.

RESULTS

Eighteen patients were enrolled in the study: 10 in video-assisted thoracoscopic surgery and 8 in conventional thoracostomy. The groups were demographically similar. No mortalities were encountered in either group, and everyone was discharged from the hospital with acceptable outcomes. Yet, there were multiple variables that demonstrated statistical difference. Hospital length of stay, number of chest tube days, narcotic use, number of radiographic procedures, and interventional procedures were all less in the patients who underwent primary video-assisted thoracoscopic surgery. In addition, no patient in the video-assisted thoracoscopic surgery group required fibrinolytic therapy, which was also statistically different from the thoracostomy drainage group.

CONCLUSIONS

The outcomes of this study strongly suggest that primary video-assisted thoracoscopic surgery for evacuation of parapneumonic effusions is superior to conventional thoracostomy drainage.

Current treatment of pediatric empyema

Pneumonia with complicated parapneumonic effusion and empyema is increasing in incidence and continues to be a source of morbidity in children seen in our institution. Current diagnostic modalities include chest radiographs and CT scanning with ultrasound being helpful in some situations. Exact management of empyema remains controversial. Although open thoracotomy drainage is well accepted in children, video-assisted thoracoscopic surgery (VATS) drainage has become more prevalent in the current era. Over the last 4 years, we have treated 58 children with intrapleural placement of pigtail catheters and administration fibrinolytics consisting of tissue plasminogen activator (tPA). Successful drainage and resolution of 54 of the 58 effusions was achieved with percutaneous methods alone. There was no mortality or 30-day recurrence. Mean hospital stay was 9.1 days (range 5 to 21) and mean chest catheter removal was 6 days post placement (range 1.5 to 20). Of the four patients that failed percutaneous tube therapy, 3 underwent video assisted thoracic surgery (VATS), and one had open thoracotomy with decortication. Based on our experience, tPA administered through a small bore chest tube for drainage of complicated parapneumonic effusions has become our standard practice. We reserve VATS for treatment failures and open thoracotomy and decortication for patients with VATS failure.

Ready for the Frontline: Is Early Thoracoscopic Decortication the New Standard of Care for Advanced Pneumonia with Empyema?

Video-assisted thoracoscopic decortication (VATD) has been established as an effective and potentially less morbid alternative to open thoracotomy for the management of empyema. However, the timing and role of VATD for advanced pneumonia with empyema is still controversial. In assessing surgical outcome, the authors reviewed their VATD experience in children with empyema or empyema with necrotizing pneumonia. The charts of 42 children who underwent VATD at our institution between July 2001 and July 2005 were retrospectively reviewed for surgical outcome. For purposes of analysis, patients were cohorted into four classes with increasing severity of pneumonia: 1 (-) intraoperative pleural fluid cultures, (-) necrotizing pneumonia, 18 (43%); 2 (+) pleural fluid cultures, (-) necrotizing pneumonia, 10 (24%); 3 (-) pleural fluid cultures, (+) necrotizing pneumonia, 6 (14%); 4 (+) pleural fluid cultures, (+) necrotizing pneumonia, 8 (19%). A P value of <0.05 via Student's t test or Fischer's exact analysis was considered an indicator of significant difference in the comparison of group outcomes. VATD was successfully completed in all 42 patients with no mortality and without significant morbidity (82% had less than 20 cc blood loss). There was found to be no significant difference (p = NS) in time to surgical discharge (removal of chest tube) among all groups. Hospital length of stay postsurgery was found to be significantly increased between 1 and 4 (6 days vs 9 days; P = 0.038). 14/14 (100%) of children with necrotizing pneumonia were found to have evidence of lung parenchymal preservation with improved aeration on follow-up CT scan and/or chest x-rays. The authors conclude that early VATD in children with advanced pneumonia with empyema is indicated to avoid unnecessarily lengthy hospitalization and prolonged intravenous antibiotic therapy. Furthermore, early VATD can be safely performed in various stages of advanced pneumonia with empyema, promoting lung salvage, and accelerating clinical recovery.

The role of thoracoscopy in the treatment of pleural empyema in children

BACKGROUND

The treatment of empyema with pleural drainage is a widely accepted surgical procedure. Currently, thoracoscopy often is used to treat this disease in some thoracic surgery centers. This report aims to present the authors' experience with the treatment of pleural empyema and the benefits of thoracoscopy.

METHODS

From 1997 to 2005, 49 children with a diagnosis of pleural empyema were treated by means of thoracoscopy in the authors' department. The study group consisted of 21 girls and 28 boys, ages 1 to 17 years (mean age, 9.2 years). Thoracoscopic cleaning and drainage of the pleural cavity was performed for all the patients.

RESULTS

Intraoperatively, stage I empyema was recognized in 7 children (14.3%), stage II in 30 children (61.2%), and stage III in 12 children (24.5%). Very good results were obtained for all the patients. There were no intra- or postoperative major complications. The drainage time was less than 5 days for 63.3% of the children. In the remaining group of patients, drainage exceeded 8 days only for 16.3%. The postoperative time was short. Emptying of the pleural cavity and full lung decompression were achieved in all cases. In four cases, pleural biopsy showed TB, which enabled early proper treatment.

CONCLUSIONS

Thoracoscopy can offer good visualization and cleansing of the empyema chambers, establishing efficient drainage even for patients with advanced stages of pleural empyema. Thoracoscopy enables collection of material not only for bacteriologic, but also for histopathologic examination. The method is minimally invasive, and risk for complication is comparable with that for classical thorax drainage.

Management of empyema in children

The incidence of empyema complicating community-acquired pneumonia is increasing and causes significant childhood morbidity. Pneumococcal infection remains the most common isolated cause in developed countries, with Staphylococcus aureus the predominant pathogen in the developing world. Newer molecular techniques utilizing the polymerase chain reaction have led to an increase in identification of causative bacteria, previously not isolated by conventional culture techniques. This remains an important epidemiological tool, and may help in guiding correct antibiotic use in the future. There are many treatment options, however, and the care a child currently receives is dependent on local practice, which is largely determined by availability of medical personnel and their preferences. Although there are many reported case series comparing treatment options, only two randomized controlled studies exist to guide treatment in children. There is an urgent need for this to be addressed, particularly with the introduction of relatively new surgical techniques such as video-assisted thorascopic surgery.

Primary operative versus nonoperative therapy for pediatric empyema: a meta-analysis

OBJECTIVE

The optimal treatment of children with empyema remains controversial. The purpose of this review was to compare reported results of nonoperative and primary operative therapy for the treatment of pediatric empyema.

METHODS

A systematic comprehensive review of the scientific literature was conducted with the PubMed (National Library of Medicine) database for the period from 1981 to 2004. This reproducible search identified all publications dealing with treatment of empyema in the pediatric population (<18 years of age). A meta-analysis was performed with studies with adequate data summaries for > or =1 of the outcomes of interest for both treatment groups.

RESULTS

Sixty-seven studies were reviewed. Data were aggregated from reports of children initially treated nonoperatively (3418 cases from 54 studies) and of children treated with a primary operative approach (363 cases from 25 studies). The populations were similar in age. Patients who underwent primary operative therapy had a lower aggregate in-hospital mortality rate (0% vs 3.3%), reintervention rate (2.5% vs 23.5%), length of stay (10.8 vs 20.0 days), duration of tube thoracostomy (4.4 vs 10.6 days), and duration of antibiotic therapy (12.8 vs 21.3 days), compared with patients who underwent nonoperative therapy. In 8 studies for which meta-analysis was possible, patients who received primary operative therapy were found to have a pooled relative risk of failure of 0.09, compared with those who did not. Meta-analysis could not be performed for any of the other outcome measures investigated in this review. Similar complication rates were observed for the 2 groups (5% vs 5.6%).

CONCLUSIONS

These aggregate results suggest that primary operative therapy is associated with a lower in-hospital mortality rate, reintervention rate, length of stay, time with tube thoracostomy, and time of antibiotic therapy, compared with nonoperative treatment. The meta-analysis demonstrates a significantly reduced relative risk of failure among patients treated operatively.