Timing of video-assisted thoracoscopic debridement for pediatric empyema

Entzündliche und infektiöse Erkrankungen der Lunge und Pleura bei Kindern und Jugendlichen

Entzündliche Erkrankungen der Lunge und Pleura bei Kindern und Jugendlichen umfassen ein weites Spektrum von der komplizierten Pneumonie, der Tuberkulose, Mykosen bis hin zur Echinokokkose. Die Häufigkeit hängt stark von der geografischen Herkunft ab. Diese Übersichtsarbeit gibt einen Überblick von der Diagnostik bis hin zur chirurgischen Therapie dieser Erkrankungen beim pädiatrischen Kollektiv.

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).

Thoracoscopy in the management of pediatric empyemas

INTRODUCTION

Thoracoscopy is increasingly being used in the treatment of empyema. This study assesses feasibility, efficacy and safety in children.

MATERIAL AND METHODS

Clinical files of patients who underwent primary thoracoscopy for empyema between 2006 and 2014 were reviewed. Demographic, clinical and surgical data were analyzed and a comparison between the period before (period1) and after (period2) the learning curve was performed.

RESULTS

Ninety-one patients (53 males, 58%) were submitted to thoracoscopy at a median age of 4 years. There were 19 conversions to thoracotomy with a steady decrease of conversion rate until 2009 (period1) and no conversions thereafter (period2). There was no difference in any of the analyzed parameters between patients submitted to thoracoscopy alone and those requiring conversion in period1. Six cases (6.6%) needed redo-operation (five in period2) and thoracotomy was the elected approach in four. Necrotizing pneumonia was present in 60% of the reoperated cases; in other words, in period2 3 out of 9 cases with necrotizing pneumonia required reintervention (p=0.07). Thoracotomy was avoided in sixty-eight (75%) patients (62% in period1 versus 92% in period2, p=0.001).

DISCUSSION AND CONCLUSIONS

Thoracoscopic approach for empyema is feasible and safe avoiding a significant number of thoracotomies after a short learning curve. An increase of reintervention rate should be expected, but throracoscopy alone is effective in the great majority of the cases. Necrotizing pneumonia may be associated with a higher risk of reintervention, as it is a contra-indication to thoracoscopy and probably surgery.

Timely thoracoscopic decortication promotes the recovery of paediatric parapneumonic empyema

INTRODUCTION

Parapneumonic empyema is one of the most commonly encountered yet difficult to manage paediatric thoracic conditions. Conservative treatment with chest tube drainage and fibrinolytic agents had been proposed but operative decortication remains the gold standard for refractory cases. Thoracoscopic decortication has been advocated in recent years due to its superiority in terms of post-operative pain, cosmesis and other long-term results. However, few studies investigated the effect of timing on peri-operative outcomes. This study aims to explore the benefits of early decortication.

METHODS

Retrospective study of all patients who underwent thoracoscopic decortication between 1999 and 2013 at a tertiary referral centre was performed. Data were extracted from respective medical records. Patients' demographics, peri-operative outcomes, length of hospitalization and post-operative complications were analysed.

RESULTS

A total of 28 patients were identified, 12 males and 16 females. Average age of patients was 4.5 years (range 12 months-14 years). Right-sided empyema was involved in 14 of the patients. Patients who underwent operation within 2 weeks from symptom onset (n = 16) showed significant shorter post-operative hospital stay (mean 9.5 vs 20.4 days, p = 0.003) and total hospitalization duration (mean 19.3 vs 38.8 days, p < 0.001). Correlation study demonstrated a strong relation between delay in operation and prolonged hospitalization (r = 0.63, p = 0.001). The peri-operative and post-operative outcomes were similar. No major post-operative complication was encountered except one patient who required a second decortication for residual empyema.

CONCLUSION

Thoracoscopic decortication is a safe and feasible procedure for parapneumonic empyema. Timely surgery is recommended as it promotes early recovery and shorter hospitalization.

Urokinase versus VATS for treatment of empyema: a randomized multicenter clinical trial

BACKGROUND AND OBJECTIVE

Parapneumonic empyema (PPE) is a frequent complication of acute bacterial pneumonia in children. There is limited evidence regarding the optimal treatment of this condition. The aim of this study was to compare the efficacy of drainage plus urokinase versus video-assisted thoracoscopic surgery in the treatment of PPE in childhood.

METHODS

This prospective, randomized, multicenter clinical trial enrolled patients aged <15 years and hospitalized with septated PPE. Study patients were randomized to receive urokinase or thoracoscopy. The main outcome variable was the length of hospital stay after treatment. The secondary outcomes were total length of hospital stay, number of days with the chest drain, number of days with fever, and treatment failures. The trial was approved by the ethics committees of all the participating hospitals.

RESULTS

A total of 103 patients were randomized to treatment and analyzed; 53 were treated with thoracoscopy and 50 with urokinase. There were no differences in demographic characteristics or in the main baseline characteristics between the 2 groups. No statistically significant differences were found between thoracoscopy and urokinase in the median postoperative stay (10 vs 9 days), median hospital stay (14 vs 13 days), or days febrile after treatment (4 vs 6 days). A second intervention was required in 15% of children in the thoracoscopy group versus 10% in the urokinase group (P = .47).

CONCLUSIONS

Drainage plus urokinase instillation is as effective as video-assisted thoracoscopic surgery as first-line treatment of septated PPE in children.

The role of tissue plasminogen activator in the management of complex intra-abdominal abscesses in children

OBJECTIVE

The objective of this study is to assess the safety of fibrinolytic therapy using tissue plasminogen activator (tPA) in children with complex intra-abdominal abscesses.

SUMMARY BACKGROUND DATA

Intra-abdominal abscesses are common in children. Antibiotics and percutaneous drainage are the mainstays of treatment, but drainage may be less effective when the fluid is thick or septated. Fibrinolytic therapy using tPA is effective in a rat model of intra-abdominal abscesses, has recently been reported for the treatment of intra-abdominal abscesses in adults, and is commonly used in the treatment of empyema in children.

METHODS

This is a retrospective review of all patients over a 10-year period who had intra-abdominal collections managed with tPA abscess drainage.

RESULTS

Sixty-four children had a total of 66 drains placed and 92 doses of tPA. Appendicitis was the cause of the abscesses in 52 of 64 children. Mean length of stay pre-tPA was 11.7 ± 7.63 days, mean time from drain insertion to tPA was 4.3 ± 3.78 days, and mean time from tPA to discharge was 8.6 ± 8.85 days. Thirty patients underwent an operation before tPA administration. No patients experienced bleeding complications, anastomotic or appendiceal stump leak, or wound dehiscence after the administration of tPA, and no patients had abnormalities in coagulation studies related to tPA administration. One child died of sepsis.

CONCLUSIONS

Tissue plasminogen activator is safe for the management of thick or septated intra-abdominal abscesses in children. A prospective controlled study will be needed to evaluate the efficacy of this technique.

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.

Management of complicated parapneumonic effusion and empyema using different treatment modalities

To evaluate the efficacy of the 3 treatment modalities (intrapleural instillation of streptokinase, video-assisted thoracoscopic surgery, thoracotomy and decortication) in the management of complicated parapneumonic effusion and empyema, a prospective study was conducted between January 2008 and June 2010. The 69 patients (52 men and 17 women, aged 18–50 years) were divided into 3 groups: 20 patients underwent intrapleural administration of streptokinase, 25 underwent video-assisted thoracoscopic surgery, and 24 had thoracotomy and decortication. Perioperative variables, mortality, and procedure success were compared among groups. In all groups, preoperative variables were well matched for age, sex, and clinical stage according to Light’s classification. No allergic or hemorrhagic complication occurred. Operative time was significantly shorter in patients undergoing video-assisted thoracoscopic surgery. There was no intraoperative complication in the 2 surgically treated groups. Length of hospital stay and duration of chest drainage were significantly shorter after video-assisted thoracoscopic surgery. Procedure success was 50% after streptokinase, 92% after video-assisted thoracoscopic surgery, and 100% after thoracotomy and decortication. There was no perioperative mortality in any group. Video-assisted thoracoscopic surgery is a safe and effective treatment modality for complicated parapneumonic effusion and pleural empyema. Earlier intervention with video-assisted thoracoscopic surgery may produce better clinical results.

Review of video-assisted thoracoscopy in children

Open thoracotomy is the standard procedure for various thoracic diseases against which other procedures are compared. Currently Video Assisted Thoracoscopic Surgery (VATS) has gained widespread acceptance in the management of a variety of thoracic disorders. It decreases the morbidity and duration of hospital stay. A total of 133 children with various thoracic diseases who presented at a University Teaching Hospital in the Department of Pediatric Surgery, from June 2000 to December 2007, were included. Of the 133 patients,116 patients had empyema, all of whom were subjected to VATS, and an attempt at debridement/decortication and drainage was made. Other thoracic disorders treated included lung abscesses, lung biopsies, hydatid cysts, and so on. Patients with empyema were treated according to their stage of disease. Of the 116 patients who underwent thoracoscopy, 16 had to be converted to open surgery due to various reasons. The mean duration for removal of drain was three days and the average total duration of hospital stay was six days. Similarly the application of VATS was advantageous in other thoracic diseases.

Video-Assisted Thoracoscopic Surgery as a Primary Intervention in Pediatric Parapneumonic Effusion and Empyema

The use and effectiveness of video-assisted thoracoscopic surgery (VATS) for the treatment of empyema and complex parapneumonic collections in pediatric patients is well documented. Timing of this intervention still remains controversial. We reviewed our experience with VATS to determine if it should be used as the initial procedure in children with pleural collections. We reviewed all pediatric (age younger than 17 years) patients with a diagnosis of pneumonia admitted between July 1998 and June 2008. Demographics, comorbidities, laboratory data, and hospital length of stay (LOS) were evaluated. Patients were divided into groups: those who only had thoracentesis or thoracostomy (Group A), those who underwent a procedure and then required VATS (Group B), and those who went directly to VATS (Group C). We identified 382 patients admitted with pneumonia. Of these, 79 (21%) required a thoracic drainage procedure. Overall, 49 (67%) of patients with a thoracic fluid collection underwent VATS at some point. With regard to type of intervention, there was no statistical difference noted in clinical variables. Thirty (38%) patients were in Group A, 18 (22%) in Group B, and 31 (39%) in Group C. LOS for Group C (10.5 days) was significantly ( P < 0.05) shorter than for both Group A (14.8 days) and Group B (15 days). Only two (6%) patients required conversion to open thoracotomy. A high percentage of children initially treated by tube thoracostomy eventually require additional interventions, leading to increased LOS. As a result of its simplicity, safety, and efficacy, VATS pleural evacuation can be recommended as the initial intervention in pediatric parapneumonic effusions and empyema in patients who do not require emergent drainage.

Toracoscopia em crianças com derrame pleural parapneumônico complicado na fase fibrinopurulenta: estudo multi-institucional

OBJETIVO: Determinar a eficácia da toracoscopia em crianças com derrame pleural parapneumônico complicado (DPPC) na fase fibrinopurulenta. MÉTODOS: Estudo retrospectivo de 99 crianças submetidas à toracoscopia para tratamento de DPPC na fase fibrinopurulenta entre novembro de 1995 e julho de 2005. A média de idade foi de 2,6 anos (variação, 0,4-12 anos) e 60% eram do sexo masculino. A toracoscopia foi realizada em três hospitais diferentes utilizando-se o mesmo algoritmo de tratamento. RESULTADOS: A toracoscopia foi eficaz em 87 crianças (88%) e 12 (12%) necessitaram de outro procedimento cirúrgico: nova toracoscopia (n = 6) ou toracotomia/pleurostomia (n = 6). O tempo médio de drenagem torácica foi de 3 dias nas crianças em que a toracoscopia foi efetiva e de 10 dias naquelas que precisaram de outro procedimento (p < 0,001). A infecção pleural de todas as crianças foi debelada após o tratamento. As complicações da toracoscopia foram fuga aérea (30%) e sangramento pelo dreno torácico (12%), enfisema subcutâneo na inserção do trocarte (2%) e infecção da ferida operatória (2%). Nenhuma criança necessitou de reoperação devido às complicações. CONCLUSÕES: A efetividade da toracoscopia em crianças com DPPC na fase fibrinopurulenta foi de 88%. O procedimento mostrou-se seguro, com baixa taxa de complicações graves, devendo ser considerado como primeira opção em crianças com DPPC na fase fibrinopurulenta.

Efficacy of video-assisted thoracoscopic surgery in managing childhood empyema: a large single-centre study

BACKGROUND/PURPOSE

A randomised controlled trial evaluating the role of video-assisted thoracoscopic surgery (VATS) in childhood empyema reported a failure rate of 16.6%. Our aim is to determine the outcome of VATS in a large series of children managed by 3 paediatric surgeons experienced in endoscopic surgery.

METHOD

A retrospective study of all children with empyema admitted under the care of the 3 surgeons between February 2004 and February 2008 was undertaken. Recorded details included demographic data, mode of presentation, preoperative investigations, operative details, antibiotic usage, microbiological data, postoperative course, follow-up data and complications.

RESULTS

114 children (69 boys, 45 girls) had VATS for empyema. Their median age was 5 (0.2-15) years. The pleural cavity was drained for a median of 4 (2-13) days. Median postoperative hospital stay was 7 (4-36) days. Median follow-up was 8 (1-24) months. There were 8 (7%) treatment failures: 5 conversions to thoracotomy and 3 recurrent empyemas. There were 7 complications (6%): air leak (n = 6) and lung injury (n = 1). 104 (91%) children had full resolution of symptoms. There were no deaths.

CONCLUSION

Video-assisted thoracoscopic surgery has a better outcome in childhood empyema than reported in a recent randomised trial and it has an important role in the management of this condition.

Toracoscopia no tratamento do empiema pleural em pacientes pediátricos

OBJETIVO: Apresentar resultados obtidos com a toracoscopia no tratamento do empiema pleural em pacientes pediátricos. MÉTODOS: Foram avaliados 117 empiemas pleurais, utilizando-se o mediastinoscópio ou a videotoracoscopia, com anestesia geral e sonda de intubação simples. As indicações para a intervenção cirúrgica foram: derrame pleural com ausência de resposta clínica e radiológica ao tratamento clínico (antibióticos, fisioterapia e toracocentese) ou sepse grave, e derrame pleural loculado (documentado por ultrassonografia ou tomografia computadorizada do tórax). RESULTADOS: De fevereiro de 1983 a julho de 2006, 117 toracoscopias foram realizadas em pacientes com idade entre 5 meses e 17 anos (média, 4 anos). O tempo médio de permanência do dreno torácico foi de 9 dias (2 a 33), e o tempo de internação hospitalar foi de 16,44 dias (4 a 49). Houve apenas um óbito (0,8%), e 33 pacientes (28%) tiveram como complicação fístula aérea prolongada. Em 7 pacientes (6%), houve necessidade de conversão para toracotomia com decorticação pulmonar em decorrência da organização do empiema. CONCLUSÕES: Não existe consenso para o tratamento do empiema pleural nesta faixa etária. A terapêutica cirúrgica é geralmente requisitada tardiamente no curso da doença, particularmente quando já existem múltiplas loculações ou quadro séptico grave. A toracoscopia indicada mais precocemente no tratamento do empiema pleural em pacientes pediátricos proporcionou uma melhor resposta à terapêutica clínica, aparentemente reduzindo o índice de morbi-mortalidade, o tempo de permanência do dreno torácico, o tempo de internação hospitalar e o tempo de antibioticoterapia.

Balloon-assisted single-port thoracoscopic debridement in children with thoracic empyema

PURPOSE

In this study, we evaluated the results of a balloon-aided single-port thoracoscopic debridement of late-stage thoracic empyema in children.

PATIENTS AND METHODS

We retrospectively reviewed age, gender, duration of prehospital illness, physical findings, surgical interventions, and the morbidity in 12 children with late-stage parapneumonic empyema. The diagnosis of pleural effusion was confirmed by a thoracocentesis before thoracoscopy. A balloon connected to a 12 F feeding tube was inserted into the thoracic cavity and inflated with air before the enterance of the thoracoscope. By this maneuver, a cavity was formed just under the enterance point. Thereafter, a routine debridement and chest irrigation was performed by thoracoscopy. Only one port was inserted in all but 1 patient, and the telescope was used as a dissecting tool. A thorax tube was inserted through the port site at the end of the procedure and left for the drainage.

RESULTS

The main symptoms of the patients were dyspnea, cough, and fever. The empyema was located on the right hemithorax in 5 patients and on the left side in 7 patients. A second port was necessary to enhance the dissection in 1 case. The chest tube was removed within 3-30 days (median, 11 days) after the surgical approach. No complication directly related to the procedure was seen. The only problems postoperatively were a self-limited and spontaneously resolved bronchopleural fistula in 4 patients, and we had to perform an additional thoracoscopy to resolve the remaining intrapleural adhesions in 1 child.

CONCLUSIONS

Thoracoscopic debridement in patients with late-stage thoracic empyema may be very beneficial, and this treatment method may provide any further thoracotomy. A balloon inflated in the thoracic cavity may achieve a wider field of vision for thorascopic surgery, and single-port thoracoscopy is sufficient and safe for the dissection.

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.

Pleural effusions

The ability to recognize, understand, and treat pleural effusions in the pediatric population is important for pediatric health care providers. The topic of pleural effusions has been extensively studied in the adult population. In recent years, these studies have extended into the pediatric population. This review describes pleural effusions in detail, including the different types and underlying pathophysiology. We then go on to provide a comprehensive review of the recent literature regarding the diagnosis and treatment of pleural effusions in the pediatric population.

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.

Video-assisted thoracic surgery--the past, present status and the future

Video-assisted thoracic surgery (VATS) has developed very rapidly in these two decades, and has replaced conventional open thoracotomy as a standard procedure for some simple thoracic operations as well as an option or a complementary procedure for some other more complex operations. In this paper we will review its development history, the present status and the future perspectives.

Comparison of thoracoscopic drainage with open thoracotomy for treatment of paediatric parapneumonic empyema

The purpose of this study was to compare the efficacy of thoracoscopic drainage with open drainage of empyema in children. A retrospective case history audit was done of children presenting to a single major paediatric centre who underwent thoracoscopy drainage and decortication or open decortication and drainage (thoracotomy) between January 2000 and September 2002. Time to resolution of infection, duration of intercostal catheter (ICC) drainage, postoperative morphine requirements, and length of hospital admission were compared as primary measures of outcome. Thirty-three patients, 17 male and 16 female, aged between 1 month and 21 years were included in the study. Median age at surgery was 2.6 years. The location of the empyema was right-sided in 17 patients and left-sided in 16 patients. The empyema was drained by thoracoscopy in 11 patients, and 22 patients underwent thoracotomy. Two patients had thoracoscopy converted to thoracotomy for late-stage disease requiring greater surgical access. There were no differences between treatment groups with respect to duration of ICC drainage (p=0.6), duration of fever (p=0.6), length of stay (p=0.9), or postoperative morphine use (p=0.2). However, overall pain scores were lower in the thoracoscopy group, particularly on days 2 and 3; this approached statistical significance (p=0.07). This study has demonstrated that thoracoscopic drainage is an effective procedure for treating empyema in children. It is less invasive than open thoracotomy and is associated with less patient discomfort and less severe pain as measured by objective pain scores. We advocate thoracoscopic drainage for the majority of patients with empyema, except for those with advanced disease.

Drainage, fibrinolytics, or surgery: a comparison of treatment options in pediatric empyema

BACKGROUND

The current treatments of pediatric empyemas include tube thoracostomy with or without the instillation of fibrinolytics, video-assisted thoracoscopic surgery (VATS), and open thoracotomy with decortication. Whereas success has been reported for all of these techniques, VATS has been suggested as the best method because of decreased length of stay.

METHODS

A chart review of children who presented with parapneumonic effusions from February 2000 to June 2002 was conducted. The patients were divided into 4 groups depending on the treatment received: group I, chest tube alone (n = 18); group II, chest tube and fibrinolytics (n = 24); group III, chest tube, fibrinolytic, and surgery (n = 5); and group IV, surgery alone (n = 6). Preadmission, in-hospital, and outcome variables for the groups were recorded and compared using the Kruskall-Wallis test, with a P value less than .05 considered significant. All the patients who received fibrinolytics (group II and III) were grouped into subjects who received immediate transpleural fibrinolytics versus those who received fibrinolytics 48 hours after chest tube insertion. Length of stay (LOS), need for surgery, and hospital costs were compared between the early and late fibrinolytic groups using the Wilcoxon rank-sum test, with a P value less than .05 considered significant.

RESULTS

Comparison of duration of symptoms, duration of preadmit antibiotics, initial white blood cell count, total lymphocyte count, and antibiotics showed no significance among the 4 groups. When comparing outcome variables, the "nonsurgery groups" (groups I and II) had shorter LOS, intensive care unit stay, and hospital charges when compared with the "surgery groups" (groups III and IV). The timing of fibrinolytic instillation (immediate versus later) did not significantly affect in the LOS, hospital charges, or the tendency to need surgery eventually in the patients who received intrapleural fibrinolytics (group II and III combined). LOS was predicted by preadmit duration of symptoms (P = .025) and overall duration of fever (P < .01). The level of pleural glucose seemed to be predictive of need for surgery (P = .015). Overall, 11 of 54 children (20.2%) eventually needed surgery.

CONCLUSIONS

Tube drainage with intrapleural instillation of fibrinolytics can be performed successfully in a large number of children with empyemas. Ultrasound characterization of the fluid and, perhaps, glucose levels may guide surgical versus nonsurgical therapy. In centers in which percutaneous drainage and tissue plasminogen activator are available, this option may be a safe and less costly alternative to surgery.

Video-assisted thoracoscopic decortication for management of postpneumonic pleural empyema

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) for decortication or debridement in the management of empyema thoracis has increased the available treatment options but requires validation. We present and evaluate our technique and experience with thoracoscopic management of pleural empyema, irrespective of chronicity.

METHODS

From May 1, 2000, to April 30, 2002, VATS debridement and decortication in 70 consecutive patients presenting with pleural space infections was performed with endoscopic shaver system. A retrospective review was performed and the effect of this technique on perioperative outcome was assessed.

RESULTS

The VATS evacuation of infected pleural fluid and decortication was successfully performed in 65 of 70 patients. The mean duration of preoperative symptoms before referral was 23 +/- 1.8 days. The mean duration of hospitalization before transfer was 13.5 +/- 1.5 days. Blood loss was 330 +/- 200 mL. Intercostal drainage was required for 5 +/- 3 days. The postoperative hospital stay was 5 +/- 0.7 days. There were no operative mortalities.

CONCLUSIONS

Video-assisted thoracoscopic decortication with endoshaver system is a simple and effective method in the management of the fibropurulent or organic pleural empyema.

Does VATS provide optimal treatment of empyema in children? A systematic review

PURPOSE

The surgical literature is replete with studies describing methods of treatment for pediatric empyema. The purpose of this report was to perform an evidence-based review of the literature to determine the most effective and appropriate treatment for empyema in infants and children.

METHODS

The MEDLINE database was searched for English- and Spanish-language articles published from 1987 through 2002 on the treatment of thoracic empyema in children. Additional unpublished data were obtained by contacting individual study authors. There were no multiinstitutional prospective studies; all were retrospective, institutional series. A true meta-analysis could not be performed because of inherent institutional bias and variability in outcome measures among studies. A Kruskal-Wallis nonparametric test was used to compare methods detailed in the individual studies.

RESULTS

Forty-four retrospective studies with a total of 1,369 patients were available for analysis. Four treatment strategies were compared: chest tube drainage alone (16 studies, 611 patients), chest tube drainage with fibrinolytic instillation (10 studies, 83 patients), thoracotomy (13 studies, 226 patients), and video-assisted thoracoscopic decortication (VATS; 22 studies, 449 patients). Outcome measures common to the majority of studies included length of stay, fever duration, l of antibiotic therapy duration, and duration of chest tube drainage. Patients undergoing early VATS or thoracotomy had shorter length of stay (P =.003). There was a trend for shorter duration of postoperative fever compared with chest tube alone or with fibrinolytic therapy, but this did not reach statistical significance (P =.055). There was no statistical difference in chest tube duration between methods. There was no trend correlating antibiotic use with treatment methods, length of hospital stay, duration of fever, or length of chest tube requirement.

CONCLUSIONS

Early VATS or thoracotomy leads to shorter hospitalization. The duration of chest tube placement and antibiotic use is variable and does not correlate with treatment method. A carefully designed, multiinstitutional, randomized study would lead to the development of evidence-based standards that may optimize the treatment of thoracic empyema in children.

Predictors of Surgical Outcome for Complicated Pneumonia in Children: Impact of Bacterial Virulence

The charts of 110 children with community acquired bacterial pneumonia were reviewed. A subset of children who required surgical intervention for empyema or parapneumonic effusion was identified. Patients were divided into two treatment groups: antibiotics/tube thoracostomy alone (group 1) versus operative intervention (group 2). Overall, 33 (30%) of the children required surgical intervention for complications. Seventeen (15%, group 1) were successfully treated with antibiotics/tube thoracostomy alone, while 16 (15%) in group 2 were treatment crossovers, failing this initial therapy. Of group 2 children, 4 (25%) underwent thoracotomy and lobectomy, while 12 (75%) underwent video-assisted thoracoscopic surgery (VATS). Although group 2 children were younger than those in group 1 (4.4 +/- 3.6 versus 6.3 +/- 4.1 years, p<0.05) and had longer hospitalizations (20.1 +/- 10.1 versus 8.2 +/- 3.9 days, p<0.05), symptom duration, preoperative antibiotics, fibrinolytic use, and leukocytosis were similar (p>0.05). Group 1 children had 13 (76%) positive cultures, 92% with pan-sensitivities, in contrast to group 2, which had 12 (75%) positive cultures, but only 33% were sensitive to first-line antibiotics (p<0.01). Group 2 patients were also more likely to have complex multi-loculated empyemas, pneumatoceles, or pulmonary necrosis identified on imaging studies (100% versus 24%, p<0.01). These data suggest that the natural history of pneumonia in children is heavily influenced by bacterial virulence. Tube thoracostomy and appropriate antibiotics remain effective for pan-sensitive, simple parapneumonic effusions and empyema. Complex parapneumonic effusions and empyema, however, which occur more frequently in the setting of first-line antibiotic resistance, often fail more conservative managements and may be best treated by earlier operative debridement.

Current issues in the diagnosis and management of pediatric empyema

Empyema is a rare but recognized complication of bacterial pneumonia in children. The incidence of empyema may be rising as vaccination practices and antibiotic prescribing practices promote the emergence of more virulent and resistant organisms. Diagnostic methods vary widely, from thoracentesis to plain radiographs to detailed computed tomography scans. Treatment practices also vary, with some practitioners preferring medical treatment, others employing chest tube drainage or fibrinolytic therapy, and still others aggressively pursuing surgical options. Further study is needed to define the ideal management of empyema. The authors review the current literature and propose an updated management algorithm that incorporates accepted practices as well as emerging trends in diagnosis and management of empyema.

Thoracoscopic decortication as first-line therapy for pediatric parapneumonic empyema. A case series

STUDY OBJECTIVES

Previous articles have promoted the early use of thoracotomy and decortication for refractory empyema. This study examines thoracoscopy and decortication at the time of initial chest tube placement in pediatric patients with parapneumonic empyema.

DESIGN

We reviewed the medical records of 16 consecutive patients who were children with parapneumonic empyema.

RESULTS

Thirteen children (group 1) underwent thoracoscopic decortication and tube thoracostomy as their initial operative procedures; 3 children (group 2) had tube thoracostomy alone. In both groups, chest tubes were removed prior to their discharge to home. The mean (+/- SD) operative time for thoracoscopy was 81 +/- 19 min with no complications. On average, chest tubes were removed by postoperative day 4. The mean time to discharge was 8.3 days. Two children eventually required lobectomy. The mean operative time for chest tube placement alone was 21 +/- 3 min. Children required chest tube drainage for an average of 12.3 days. The mean time to discharge was 16.6 days. Two patients required a total of five additional operative procedures, including two additional chest tube placements, two open decortications, and one lobectomy.

CONCLUSIONS

Thoracoscopic decortication is effective in the early treatment of pediatric parapneumonic empyema. It facilitates visualization, evacuation, and mechanical decortication of the pleural space with no additional morbidity and may lead to reduced time for chest tube drainage, shorter hospitalization, and more rapid clinical recovery.

Efficacy of primary and secondary video-assisted thoracic surgery in children

BACKGROUND/PURPOSE

Video-assisted thoracic surgery (VATS) is used commonly for diagnostic and therapeutic procedures in children. The purpose of this study was to determine the accuracy, efficacy, and complications associated with primary and secondary VATS in children.

METHODS

Eighty-seven infants, children, and adolescents underwent 104 VATS procedures between March 1993 and April 1999. There were 47 boys and 40 girls with an age range of 6 months to 19 years. VATS was performed for excision of pulmonary nodule (n = 51), biopsy of infiltrate (n = 14), excision or biopsy mediastinal mass (n = 12), decortication of empyema (n = 16), pleurodesis and bleb excision for pneumothorax (n = 5), pleurolysis for P32 administration (n = 3), esophageal myotomy (n = 2), and thymectomy (n = 1). In 6 children a contralateral thoracic procedure was performed along with VATS (3 VATS, 3 thoracotomies). Secondary VATS was performed in 20 after prior thoracic procedures.

RESULTS

VATS was efficacious for diagnostic or therapeutic purposes in 93 cases. Overall, 11 (11%) VATS required conversion to open thoracotomy. Average length of thoracostomy tube drainage (CTD) was 2.2 days, and average length of stay (LOS) was 3.7 days. Complications included prolonged air leak (> 7 days) in 3 (2 empyema, 1 nodule). Two children with malignancy and pulmonary infiltrates died within 30 days of progressive respiratory failure. There were no bleeding complications or deaths related to VATS.

CONCLUSIONS

VATS is a safe and effective primary and secondary procedure in children resulting in a short length of CTD and LOS. Duration of CTD and LOS are prolonged if empyema is associated with a bronchopleural fistula, and VATS may not be of value in this setting.

Video-assisted evacuation of empyema is the preferred procedure for management of pleural space infections

BACKGROUND

Empyema remains a cause of morbidity and mortality. Thoracoscopy has proved its versatility in the management of pleural space disorders. The suitability of video-assisted thoracic surgery (VATS) for decortication in the management of the fibrotic stage of empyema is unclear.

METHODS

VATS evacuation of empyema and decortication was performed on seventeen patients presenting with pleural space infections. A retrospective review was performed and constitutes the basis of this report.

RESULTS

VATS evacuation of empyema and decortication was successfully performed in 13 of 17 patients. Blood loss was 325 +/- 331 cc. Mean hospital stay was 18 +/- 10 days. Postoperative hospitalization was 11 +/- 7 days. Chest tubes remained in place for 7 +/- 3 days. There were no operative mortalities.

CONCLUSIONS

Video-assisted evacuation of empyema and decortication is an effective modality in the management of the exudative and fibrinopurulent stages of empyema. An organized empyema should be approached thoracoscopically, but may require open decortication.