How should we manage empyema: antibiotics alone, fibrinolytics, or primary video-assisted thoracoscopic surgery (VATS)?

Uniportal Video-Assisted Thoracoscopic Surgery for Minor Procedures

INTRODUCTION

Uniportal video-assisted thoracoscopic surgery (uVATS) is becoming popular for major lung resections, even for more complex procedures. The technique initially described for minor procedures seems more difficult to reproduce and has a longer learning curve. This review aims to describe the evolution from multiportal to uVATS and to explore its feasibility and reproducibility by identifying its drawbacks and limitations.

METHODS

Research from PubMed was obtained with the terms [uniportal] AND [surgery] OR [single-port] AND [thoracic surgery] OR [VATS]. Papers concerning pediatric cases and non-English papers were excluded. Individual case reports were also excluded.

DISCUSSION

uVATS seems to be widely adopted and performed for minor procedures. The applicability of uVATS for different indications is discussed, even though practically all thoracic surgical interventions can be performed through a single incision.

CONCLUSIONS

The transition from conventional three-port VATS to uVATS is described in this paper. An increasing number of thoracic surgeons worldwide have adopted this approach, even for major complex anatomical lung resections. Regarding the performance of minor thoracic interventions, we believe this technique is easily reproducible with a short learning curve because the instruments do not cross each other, and intraoperative movements remain intuitive. It is therefore a feasible, safe, and efficacious technique. For these reasons, we believe uVATS should be offered to all patients undergoing minor thoracoscopic procedures.

Single Trocar Thoracoscopic Surgery for Pleural Empyema in Children

Aim: To present outcomes of single trocar thoracoscopic surgery in the treatment of pleural empyema (PE) in children. Patients and Methods: The thoracoscopic surgery was performed using a single trocar inserted through the fifth intercostal space. A conventional rigid scope with a working channel was used. Pleural fluid was aspirated, followed by debridement and ablation of all septa using one instrument through the working channel. Results: Sixty patients from 1 month to 14 years of age underwent surgery without any intraoperative complications or death. The mean operative time was 67 ± 21 minutes. There was no conversion to open thoracotomy. Postoperative complications occurred in 4 patients. Reoperation was required in 1 patient. Mean duration of postoperative hospitalization was 15 ± 9 days. Follow-up was obtained in 57 patients and resulted in normal clinical and chest X-ray findings in all patients. Conclusion: Single trocar thoracoscopic operation is safe, feasible, and effective in the treatment of PE in children. A future study with control group is required to draw accurate conclusions.

Pediatric empyema thoracis management: should the consensus be different for the developing countries?

BACKGROUND

Despite the available consensus, intrapleural fibrinolytic therapy (IFT) in pediatric empyema is grossly underutilized in the Indian subcontinent where the disease burden is huge. Possible reasons may be epidemiological differences and physician bias. There is a paucity of literature from developing countries on the use of IFT in pediatric empyema thoracis. Hence, this study was undertaken to determine if fibrinolytic therapy is equivalent to video-assisted thoracoscopic surgery (VATS) in treating stage II empyema in children even in developing countries.

METHODS

Consecutive cases of stage II empyema were randomized to receive either IFT or VATS. The outcomes measured were the duration of hospital stay, efficacy of therapy, complications, and cost differences.

RESULTS

41 children were randomized to either VATS (n = 20) or IFT (n = 21) group. Overall successful clearance of empyema was achieved in 18 out of 20 (90%) children undergoing VATS and 20 out of 21(95.2%) children in fibrinolytic arm. The median length of the hospital stay was 7 and 8 days for VATS and IFT groups respectively (p = .24). Need for CT scan and blood transfusion was significantly higher in the VATS group than IFT group (p = .02 and .000).

CONCLUSIONS

Fibrinolytic therapy is noninferior to VATS in the treatment of stage II empyema in children in the Indian subcontinent. A multicenter trial with larger sample size and uniform, detailed protocols on indications for CT scan, blood transfusions, nutrition status and costs involved will be needed to eliminate institutional bias and to increase the strength of the study.

STUDY TYPE

Randomized controlled study, treatment study and cost effectiveness study.

Resolution of Empyema Thoracis after Patient Refusal of Surgical Intervention: A Case Series and Review of the Literature

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Parapneumonic effusions occur commonly in patients hospitalised with pneumonia. Both complicated parapneumonic effusions and empyema are often managed initially with tube thoracostomy and intrapleural t-PA and DNase. If complete expansion of the lung is not achieved, surgical intervention is considered. We present three cases of patients with complicated parapneumonic effusions who experienced complete recovery despite declining surgical intervention and discuss the pitfalls in management. While very few patients have complete radiological resolution at the time of discharge, medical therapy is successful in at least 90% of cases. At 3-6 months from presentation, the radiological findings may improve significantly with antibiotic therapy. Surgery should be considered for patients with non-resolving sepsis markers including elevated temperature, C-reactive protein, and white blood cell count, in addition to non-improving imaging. Incomplete resolution of the parapneumonic effusion should not be considered a treatment failure, and attempts to normalise CT imaging may result in prolonged hospitalisation and unnecessary surgical intervention.

Management of paediatric empyema by video-assisted thoracoscopic surgery (VATS) versus chest drain with fibrinolysis: Systematic review and meta-analysis

BACKGROUND

The ideal surgical approach for empyema in children (≤18 years) remains controversial. Video assisted thoracoscopic surgery (VATS) and chest drain with fibrinolysis (CDF) are both accepted methods. The aim of this study was to clarify which of these two techniques provides the best clinical outcome.

METHODS

A systematic review and meta-analysis (1997-2018) was conducted. We used the random-effect model to produce risk ratio (RR) for categorical variables, and standard difference in means (SDM) for continuous variables, along with 95% confidence intervals [CI]. I² value was used to assess heterogeneity. P values <0.05 were considered significant.

RESULTS

We identified 707 studies: 10 studies were included in the final analysis. The incidence of total peri-operative complications was not different between the two groups (RR 0.6 [CI: 0.3-1.2], p = 0.2; I² = 0.0%; p = 0.6). Need for re-intervention was significantly lower in the VATS group (RR 0.55 [CI: 0.34-0.88], p = 0.01; I² = 14.4%; p = 0.3). Post-operative length of hospital stay was significantly shorter in the VATS group (SDM -0.45 [CI: -0.78 to -0.12], p = 0.007; I² = 88%; p = 0.001).

CONCLUSIONS

Current evidence suggests that VATS and CDF for empyema in children have a similar incidence of peri-operative complications. However, VATS seems associated with reduced need for re-intervention and shorter post-operative hospital stay.

Computed tomography-guided catheter drainage with urokinase and ozone in management of empyema

AIM

To retrospectively compare the outcomes of catheter drainage, urokinase and ozone in management of empyema.

METHODS

Retrospective study included 209 patients (111 males and 98 females; age range 19 to 72 years) who were diagnosed with empyema. The patients were divided into 3 groups based on the therapy instituted: catheter drainage only (group I); catheter drainage and urokinase (group II); catheter drainage, urokinase and ozone (group III). Drainage was considered successful if empyema was resolved with closure of cavity, clinical symptoms were resolved, and need for any further surgical procedure was avoided. Success rate, length of stay (LOS), need for further surgery and hospital costs were compared between the three groups using the Kruskall-Wallis nonparametric test, with P < 0.05 considered significant.

RESULTS

Of the 209 patients with empyema, all catheters were placed successfully under CT guidance. Sixty-three patients were treated with catheters alone (group I), 64 with catheters and urokinase (group II), and 82 with catheters, urokinase and ozone (group III). Group I, group II and group III had success rates of 62%, 83% and 95% respectively (P < 0.05). Group I and group II had statistically longer LOS (P < 0.05) and higher hospital costs (P < 0.05) compared to group III. There were statistically significant differences between the three groups when comparing patients who converted into further surgery.

CONCLUSION

The combination of chest tube drainage, urokinase and ozone is a safe and effective therapeutic modality in thoracic empyema.

Survey of hospital procedures for parapneumonic effusion in children highlights need for standardised management

AIM

This study sought to evaluate the initial management of children with parapneumonic effusion admitted to all French university hospitals.

METHODS

A nationwide survey of all 35 university hospitals took place in 2011 to assess practices for children with parapneumonic effusion, using a hypothetical clinical vignette and a standardised questionnaire. Two to four paediatricians per hospital were interviewed and asked about their initial management, probabilistic antibiotic therapy and its adaptation to microbiological results and subsequent course. Answers from paediatricians working in emergency departments, intensive care units and conventional paediatric units were compared.

RESULTS

Of the 100 paediatricians contacted, 95 responded. Of these, 98% would order an initial blood test, 70% would order diagnostic thoracentesis, and all would start immediate antibiotic therapy: 31% with a single drug, 67% with two drugs and 2% with three drugs. The most frequent initial choices were third-generation cephalosporin alone (17%) or combined with rifampicin (34%) or vancomycin (24%). Adaptation varied according to drug used, dose and duration, especially when the microorganism was not Streptococcus pneumoniae. Practices did not differ significantly among the different groups of paediatricians.

CONCLUSION

Standardised management of parapneumonic effusion, including routine thoracentesis and more consistent prescription of antibiotics, is needed.

Management of pleural empyema with single-port video-assisted thoracoscopy

OBJECTIVE

The aim of this study was to evaluate the safety and efficacy of an original technique of single-port video-assisted thoracoscopy (S-VATS) for the minimally invasive treatment of pleural empyema in fibrinopurulent stage.

METHODS

Single-port video-assisted thoracoscopy was performed under general anesthesia and single-lung ventilation using a 2-cm incision after ultrasound localization of the projected midpoint of the pleural effusion. Through the single access, a video scope and standard thoracoscopy instruments were simultaneously introduced to perform debridement and lavage of the pleural cavity. Postoperatively, patients underwent continuous or intermittent pleural irrigation through the chest tube until microbiological confirmation of sterility of the pleural fluid.

RESULTS

Between November 2004 and December 2009, a total of 61 patients underwent S-VATS for pleural empyema in stage I (7%) or II (93%). Median age was 63.5 years (range, 22-94 years). Male-to-female ratio was 4.2. Surgery was performed 3 to 60 days after the onset of symptoms. Macroscopically complete debridement of the pleural cavity was achieved in most (98%) cases. Median operation time was 53 minutes (range, 29-90 minutes). No intraoperative complications occurred. In-hospital mortality and morbidity rates were 3% and 16%, respectively. Deaths were caused by diffuse metastatic colon cancer in one case and severe apoplectic insult in the other. Chest tube was removed after a median time of 12 days (range, 4-64 days). Four (6.5%) patients experienced a relapse of empyema; this was caused by complicated residual pleural space (two cases), persistent pleuropulmonary fistula (one case), or both (one case).

CONCLUSIONS

It seems that S-VATS is a safe and effective procedure for the treatment of pleural empyema in fibrinopurulent stage.

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.

Impact of an evidence-based algorithm on quality of care in pediatric parapneumonic effusion and empyema

OBJECTIVE

To determine whether implementation of a collaborative, evidence-based algorithm for care of pediatric parapneumonic effusion and empyema (PPE) can improve the quality of care delivered.

STUDY DESIGN

Prospective cohort with retrospective control comparison of children aged 1 month to 18 years admitted with a clinical diagnosis of PPE. Quality improvement techniques were used to develop an algorithm, which was implemented September 2008. Primary outcome measures were decreased median and variability in length of stay (LOS), reduction in the use of chest computed tomography (CT), reduction in the total number of painful procedures, and increased initial use of effective drainage procedures when drainage was indicated.

RESULTS

Compared with controls, algorithm implementation substantially reduced use of chest CT (0% vs. 41% of patients, P = 0.01) with no observed negative impact on LOS. Reductions in median LOS were not significant, but variability in LOS was reduced (P < 0.01 by F-test). Changes in number of procedures and use of effective drainage when indicated were in the predicted direction but not statistically significant.

CONCLUSIONS

Quality improvement techniques are an effective means for incorporating evidence-based medicine into pediatric care. PPE can be managed safely without the use of chest CT.

Infection in pediatric interventional radiology

Interventional radiology in children involves nearly every aspect of infectious disease. Diagnosis, treatment, prophylaxis and disease transmission in infectious disease are a daily part of pediatric interventional radiology practice. This article will discuss each of these aspects of infection with respect to interventional radiology.

Management of children with empyema: Pleural drainage is not always necessary

BACKGROUND

There is considerable variation in the management of pediatric empyema, and there are no clear criteria for when to perform pleural drainage. Our study aims were: (1) to retrospectively review our experience with an empyema treatment strategy that started with intravenously administered (IV) antibiotics alone in medically stable patients with procession to pleural drainage only if there was no clinical improvement after 48 hr, and (2) to identify predictors for undergoing pleural drainage.

METHODS

We performed a retrospective review of 182 previously healthy children, 1-18 years old, hospitalized with empyema from December 1996 through December 2008. The primary outcome measures were the proportion of patients requiring pleural drainage procedures and hospital length of stay (LOS).

RESULTS

Ninety-five children (52%) received antibiotics alone, and 87 (45%) underwent drainage procedures (21 chest tube alone, 57 VATS/thoracotomy, and 8 chest tube followed by VATS/thoracotomy); only 4 received fibrinolytics. Mean (standard deviation) LOS was significantly shorter in the antibiotics alone group, 7.0 (3.5) versus 11 (4.0) days. The strongest predictors of undergoing pleural drainage were admission to the intensive care unit and large effusion size (>(1/2) thorax filled).

CONCLUSIONS

Some children with empyema can be treated with IV antibiotics alone and have reasonably short LOS. At our institution, those that required intensive care or had large effusions with mediastinal shift were more likely to require pleural drainage.

Position paper on video-assisted thoracoscopic surgery as treatment of pediatric empyema

Pediatric empyema can be managed with a variety of modalities, and the evidence for an ideal management strategy is limited. Early or simple effusions can be treated with antibiotics alone or with drainage when respiratory distress occurs. Once fibrinopurulent empyema has developed, therapy may involve either chest tube placement with instillation of fibrinolytics or video-assisted thoracoscopic surgery with pleural decortication. In late or fibrotic empyema, an assumption persists that the fibrotic peel must be managed by decortication that can be done either thoracoscopically or through a minithoracotomy incision. This position paper is coauthored by the New Technology Committee of the American Pediatric Surgery Association. The goal is to discuss the ongoing controversies and summarize, in an evidence-based manner, the various treatment options and to suggest a reasonable therapeutic algorithm for the care of children with empyema.

Recent advances and controversies in pediatric laparoscopic surgery

Children represent a unique group of patients who are likely to greatly benefit from minimally invasive surgery (MIS). The promise of less postoperative pain, smaller scars, shorter hospital stays, and a faster return to school continues to drive growth in this area. The development of pediatric-specific techniques and documentation of improved outcomes form a critical gateway to widespread application of pediatric MIS. A brief perspective on current approaches to MIS for pediatric congenital and acquired disease is provided in this report. Technical departures from standardized adult MIS and the rationale for their modification are highlighted.

Survey of childhood empyema in Asia: implications for detecting the unmeasured burden of culture-negative bacterial disease

Background

Parapneumonic empyema continues to be a disease of significant morbidity and mortality among children despite recent advances in medical management. To date, only a limited number of studies have assessed the burden of empyema in Asia.

Methods

We surveyed medical records of four representative large pediatric hospitals in China, Korea, Taiwan and Vietnam using ICD-10 diagnostic codes to identify children <16 years of age hospitalized with empyema or pleural effusion from 1995 to 2005. We also accessed microbiology records of cultured empyema and pleural effusion specimens to describe the trends in the epidemiology and microbiology of empyema.

Results

During the study period, we identified 1,379 children diagnosed with empyema or pleural effusion (China, n = 461; Korea, n = 134; Taiwan, n = 119; Vietnam, n = 665). Diagnoses of pleural effusion (n = 1,074) were 3.5 times more common than of empyema (n = 305), although the relative proportions of empyema and pleural effusion noted in hospital records varied widely between the four sites, most likely because of marked differences in coding practices. Although pleural effusions were reported more often than empyema, children with empyema were more likely to have a cultured pathogen. In addition, we found that median age and gender distribution of children with these conditions were similar across the four countries. Among 1,379 empyema and pleural effusion specimens, 401 (29%) were culture positive. Staphylococcus aureus (n = 126) was the most common organism isolated, followed by Streptococcus pneumoniae (n = 83), Pseudomonas aeruginosa (n = 37) and Klebsiella (n = 35) and Acinetobacter species (n = 34).

Conclusion

The age and gender distribution of empyema and pleural effusion in children in these countries are similar to the US and Western Europe. S. pneumoniae was the second leading bacterial cause of empyema and pleural effusion among Asian children. The high proportion of culture-negative specimens among patients with pleural effusion or empyema suggests that culture may not be a sufficiently sensitive diagnostic method to determine etiology in the majority of cases. Future prospective studies in different countries would benefit from standardized case definitions and coding practices for empyema. In addition, more sensitive diagnostic methods would improve detection of pathogens and could result in better prevention, treatment and outcomes of this severe disease.