Early video-assisted thoracic surgery in the management of empyema

A Global Bibliometric Analysis of the Top 100 Most Cited Articles on Early Thoracotomy and Decortication in Pleural Empyema

Most pleural empyema cases are linked to pneumonia, a substantial fraction of patients present with empyema without any association to pneumonia. The occurrence of empyema caused by tuberculosis (TB) is increasing in regions where TB is prevalent. In May 2024, a bibliometric analysis was conducted involving the screening of 7,620 articles sourced from Google Scholar. Google Scholar was selected for its comprehensive nature, encompassing articles indexed in prominent databases like Web of Science, Scopus, and PubMed. This allowed access to significant studies that might be overlooked if they were not indexed by these databases. Articles were selected based on their citation count and specific inclusion criteria, focusing on early thoracotomy and decortication in pleural empyema. Two authors (VB and MK) independently conducted a thorough screening and data collection. The hundred top articles published from 1945 to 2015, garnered a total of 16,928 citations. These articles were written by 93 distinct first authors from 22 countries and 83 institutions, and were featured in 35 journals. The primary categories of literature included those describing the disease characteristics, features, causes, and types of pleural empyema, as well as various treatment modalities and management strategies, each constituting 37% of the literature. Additionally, pediatric empyema was a focus in 11% of the articles. The present analysis highlights publication trends, identifies gaps in the literature, and suggests areas for future research, serving as a valuable resource for guiding upcoming studies on early thoracotomy and decortication in pleural empyema.

Loculations and Associated Risk Factors of Childhood Pleural Tuberculosis

Background: Pleural loculation in childhood pleural tuberculosis (TB) remains a problem in practice, it is usually associated with failure drainage. Therefore, to improve the management of childhood pleural TB, a retrospective study was conducted to identify the risk factors associated with loculated effusion in childhood pleural TB. Methods: Between January 2006 and December 2019, consecutive children (≤15 years old) with tuberculous pleural effusion (definite and possible) were included for further analysis. The demographic, clinical, laboratory, and radiographic features were collected from the medical records. Univariate and multivariate logistic regressions were used to explore the factors associated with the presence of pleural loculation in children with pleural TB. Results: A total of 154 children with pleural TB (definite, 123 cases; possible, 31 cases) were included in our study and then were classified as loculated effusion (n = 27) and non-loculated effusion (n = 127) groups by chest X-ray or ultrasonography. Multivariate analysis revealed that male gender (age-adjusted OR = 3.903, 95% CI: 1.201, 12.683), empyema (age-adjusted OR = 4.499, 95% CI: 1.597, 12.673), peripheral monocytes ≤0.46 × 10⁹/L (age-adjusted OR = 4.122, 95% CI: 1.518, 11.193) were associated with the presence of loculated effusion in children with pleural TB. Conclusion: In conclusion, several characteristics, such as male gender, empyema, and peripheral monocyte count have been identified as risk factors for pleural loculation in children with pleural TB. Our findings may be helpful to improve the management of pleural loculation in childhood pleural TB.

Video-assisted thoracic surgery for the management of pyothorax in dogs: 14 cases

OBJECTIVE

To report the perioperative findings and outcome of dogs undergoing video-assisted thoracic surgery (VATS) for the management of pyothorax.

DESIGN

Multi-institutional, retrospective study.

ANIMALS

Client-owned dogs (n = 14).

METHODS

Medical records of dogs with pyothorax managed via VATS were reviewed for signalment, history, clinical signs, clinicopathological findings, diagnostic imaging results, surgical variables, bacterial culture and sensitivity results, post-operative management and outcome. VATS was performed after placing a paraxyphoid endoscopic portal and 2-3 intercostal instrument portals. VATS exploration was followed by one or more of the following: mediastinal debridement, tissue sampling, pleural lavage, and placement of a thoracostomy tube.

RESULTS

Two dogs (14%) required conversion from VATS to an open thoracotomy to completely resect proliferative mediastinal tissue. These dogs had severe pleural effusion on preoperative thoracic radiographs and one had severely thickened contrast-enhancing mediastinum on preoperative computed tomography (CT). The cause of pyothorax was identified as a penetrating gastric foreign body (n = 2), migrating plant material (n = 2), and idiopathic (n = 10). The median follow-up time was 143 days (range, 14-2402 days). All dogs were discharged from the hospital and their clinical signs resolved. One patient had recurrence of a pyothorax requiring revision surgery 17 months postoperatively.

CONCLUSION

VATS allows minimally invasive treatment of uncomplicated canine pyothorax. Preoperative thoracic CT may help identify candidates for VATS among dogs with pyothorax.

Tissue Plasminogen Activator as an Adjuvant Therapy for Pleural Empyema in Pediatric Patients

The authors retrospectively review the clinical course and outcome of 6 pediatric patients, ranging in age from 2 to 13 years, who were treated with TPA for complex empyema. Efficacy was assessed by evaluating pleural fluid drainage for 6 hours prior to and subsequent to each dose of TPA, as well as by resolution of fever and length of hospital stay. The average volume drained for 6 hours before infusion of TPA was 22.5 mL ± 18.4 mL, and the average volume 6 hours after TPA therapy was 141.7 mL ± 28.3 mL, P < .0001. After initiation of TPA therapy, 5 out of 6 patients became afebrile within 48 hours. The median length of stay after initiation of TPA therapy was 6 days, with a range from 4 days to 12 days. A discussion of other current therapies for empyema, along with a comparison of these therapies to TPA regarding the costs of therapies and risk-benefit ratios, is also included.

A clinical review of the pathophysiology, diagnosis, and treatment of pyothorax in dogs and cats

OBJECTIVE

To review the current literature in reference to the pathophysiology, diagnosis, and treatment of pyothorax in dogs and cats.

ETIOLOGY

Pyothorax, also known as thoracic empyema, is characterized by the accumulation of septic purulent fluid within the pleural space. While the actual route of pleural infection often remains unknown, the oral cavity and upper respiratory tract appear to be the most common source of microorganisms causing pyothorax in dogs and cats. In human medicine, pyothorax is a common clinical entity associated with bacterial pneumonia and progressive parapneumonic effusion.

DIAGNOSIS

Thoracic imaging can be used to support a diagnosis of pleural effusion, but cytologic examination or bacterial culture of pleural fluid are necessary for a definitive diagnosis of pyothorax.

THERAPY

The approach to treatment for pyothorax varies greatly in both human and veterinary medicine and remains controversial. Treatment of pyothorax has classically been divided into medical or surgical therapy and may include administration of antimicrobials, intermittent or continuous thoracic drainage, thoracic lavage, intrapleural fibrinolytic therapy, video-assisted thoracic surgery, and traditional thoracostomy. Despite all of the available options, the optimal treatment to ensure successful short- and long-term outcome, including the avoidance of recurrence, remains unknown.

PROGNOSIS

The prognosis for canine and feline pyothorax is variable but can be good with appropriate treatment. A review of the current veterinary literature revealed an overall reported survival rate of 83% in dogs and 62% in cats. As the clinical presentation of pyothorax in small animals is often delayed and nonspecific, rapid diagnosis and treatment are required to ensure successful outcome.

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.

Pneumothorax necessitans in a patient with trapped lung and rheumatoid arthritis

The authors report the case of a patient with a background of trapped lung following thoracocentesis who developed an anterolateral intercostal pneumothoracocele resulting in a pneumothorax necessitans (PN). Our purpose is to highlight the pathophysiology and interesting radiological features associated with PN in trapped lung. Our case is particularly unique due to the subacute nature of its presentation in a patient with rheumatoid arthritis and unusual pre-existing lung pathology.

Empyema thoracis: analysis of 150 cases from a tertiary care centre in North East India

OBJECTIVES

To analyze the clinical characteristics, microbiological profile, management, complications and outcome of cases with empyema thoracis.

METHODS

All cases diagnosed as 'empyema thoracis' over a period from January 2006 through June 2010 were identified from the inpatient records and discharge summaries. Of the 160 cases identified, 150 cases were taken up for analysis and the rest 10 cases, of which two had significant predisposing co-morbidity and eight cases diagnosed as tubercular empyema thoracis were excluded from the analysis.

RESULTS

Mean age of presentation was 4.74 ± 3.53 years and two thirds of the children were under 5 years with male to female ratio of 1.42:1. Pus culture was positive in 32% (48 cases) with Streptococcus pneumoniae being the commonest organism isolated (31 cases, 64.6%) followed by Staphylococcus aureus (11 cases, 22.9%), Klebsiella pneumoniae (3 cases, 6.3%), Haemophilus influenzae type b (2 cases, 4.2%) and Enterococcus (1 case, 2%). Clustering was seen in the hot and humid months from April to July (63.3%). Fever was the commonest presentation (96.7%) followed by cough (90%), breathing difficulty (66.7%), chest pain (26.7%) and pain abdomen (10.7%). Ampicillin and cloxacillin was used as the first line antibiotic in 57.3% cases. Average duration of intercostal water seal drainage (ICWSD) in situ was 13.5 ± 8.05 days and 59 patients (39.3%) received fibrinolytic therapy. The commonest complications were collapse (18%), thickened pleura (16.7%), pericardial effusion (8%), cardiac tamponade (3.3%) and bronchopleural fistula (3.3%). Surgical procedures involved in this case series were decortication (14 cases, 9.3%), pericardiocentesis (5.3%), pericardiostomy (2.7%) and pericardiectomy (1.6%). Mortality was 3.3%.

CONCLUSIONS

This is the first report of empyema thoracis from the north eastern region of India. Streptococcus pneumoniae was found to be the leading cause of empyema thoracis in this case series. Conservative management with ICWSD and antibiotics or early use of fibrinolytic therapy if indicated are effective modalities of treatment.

The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America

Evidenced-based guidelines for management of infants and children with community-acquired pneumonia (CAP) were prepared by an expert panel comprising clinicians and investigators representing community pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine, infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care and subspecialty providers responsible for the management of otherwise healthy infants and children with CAP in both outpatient and inpatient settings. Site-of-care management, diagnosis, antimicrobial and adjunctive surgical therapy, and prevention are discussed. Areas that warrant future investigations are also highlighted.

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.

[Treatment of loculated parapneumonic empyema. Video assisted thoracoscopy or fibrinolytics?]

OBJECTIVE

There is no consensus regarding the ideal treatment of loculated parapneumonic empyema (PPE). The aim of this study is to compare the effectiveness of drainage plus urokinase (DF) with video-assisted thoracoscopy (VATS).

MATERIAL AND METHODS

Retrospective review. Patients admitted with a PPE between January 2001 and July 2008. Loculated empyema was diagnosed by chest ultrasound and patients were treated with DF or VATS depending on the attending surgeon. Compared variables were: post-operative stay, total hospital stay, days of tube thoracostomy, post-operative fever and treatment failure.

RESULTS

One hundred and twenty one patients were admitted with the diagnosis of PPE. Seventeen patients were excluded from analysis because of simple parapneumonic effusions. Of the 104 patients included in the study, 47 were treated with urokinase and 57 with videothoracoscopy. No statistically significant differences (P>.05) were found between the median values in the DF and VATS groups for hospital stay (median 12 vs 12 days) or post-operative stay (median 9 vs 9 days). There were differences in duration of tube thoracostomy (median DF group 5 days, VATS, 4 days, P<.05) and in the post-operative fever (median 3 vs 2 days, p<0,05).Twenty two per cent of children needed a second procedure (14 patients of DF and 9 of VATS group, P=.09).

CONCLUSIONS

According to our experience, the results of DF and VATS for the treatment of loculated parapneumonic empyema are similar. Although there are no statistical differences, there seems to be a higher rate of failure, with the need of more procedures in the DF group. This difference does not affect the average total hospital stay.

Comparative effectiveness of pleural drainage procedures for the treatment of complicated pneumonia in childhood

OBJECTIVE

To determine the comparative effectiveness of common pleural drainage procedures for treatment of pneumonia complicated by parapneumonic effusion (ie, complicated pneumonia).

DESIGN

Multicenter retrospective cohort study.

SETTING

Forty children's hospitals contributing data to the Pediatric Health Information System.

PARTICIPANTS

Children with complicated pneumonia requiring pleural drainage.

MAIN EXPOSURES

Initial drainage procedures were categorized as chest tube without fibrinolysis, chest tube with fibrinolysis, video-assisted thoracoscopic surgery (VATS), and thoracotomy.

MAIN OUTCOME MEASURES

Length of stay (LOS), additional drainage procedures, readmission within 14 days of discharge, and hospital costs.

RESULTS

Initial procedures among 3500 patients included chest tube without fibrinolysis (n = 1762), chest tube with fibrinolysis (n = 623), VATS (n = 408), and thoracotomy (n = 797). Median age was 4.1 years. Overall, 716 (20.5%) patients received an additional drainage procedure (range, 6.8-44.8% across individual hospitals). The median LOS was 10 days (range, 7-14 days across individual hospitals). The median readmission rate was 3.8% (range, 0.8%-33.3%). In multivariable analysis, differences in LOS by initial procedure type were not significant. Patients undergoing initial chest tube placement with or without fibrinolysis were more likely to require additional drainage procedures. However, initial chest tube without fibrinolysis was the least costly strategy.

CONCLUSION

There is variability in the treatment and outcomes of children with complicated pneumonia. Outcomes were similar in patients undergoing initial chest tube placement with or without fibrinolysis. Those undergoing VATS received fewer additional drainage procedures but had no differences in LOS compared with other strategies.

Video-assisted thoracoscopic surgery of childhood empyema: early referral improves outcome

BACKGROUND/AIM

Video-assisted thoracoscopic surgery (VATS) is considered a safe and effective option in the treatment of childhood empyema. The aim of this study was to assess the efficacy of early referral for primary VATS in childhood empyema.

METHOD

A cohort of 24 consecutive children (12 boys, 12 girls) from 2004 to 2009 with post-pneumonic empyema, as demonstrated by loculation on ultrasound, undergoing VATS at a single tertiary level institution, was reviewed. All cases of empyema were managed as per the local protocol of early referral for primary VATS.

RESULTS

Mean age of presentation was 54 months (5 months to 15 years). Mean duration of symptoms before presentation to our centre was 6.29 days (±2.74 days) (range 1-10 days) and mean time to referral to the paediatric surgical unit was 1.95 days (±2.57 days). VATS was performed in all patients with a mean operating time 113.7 min (±37.0 min), which included time for bronchoscopy (range 43-184 min). The mean duration of chest drainage was 4 days (±2.96 days) and post-operative hospitalisation was 6.88 days (±4.11 days).

CONCLUSION

Early primary VATS for post-pneumonic empyema in children demonstrated a higher success rate, lower conversion to open thoracotomy improved outcome and shorter hospitalisation.

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.

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.

[Intrapleural streptokinase in the treatment of complicated parapneumonic empyema]

INTRODUCTION

Parapneumonic empyema is a frequent cause of admission in the Pediatric Hospital of the Pereira Rossell Hospital Center. In January 2005, we implemented a treatment protocol that included intrapleural streptokinase (STK) for children with complicated parapneumonic empyema as an alternative to surgery.

OBJECTIVES

To describe the results of intrapleural STK in the treatment of hospitalized children with complicated parapneumonic empyema and to compare these results with those of early thoracotomy.

PATIENTS AND METHODS

Children with complicated parapneumonic empyema admitted between January 1st 2004 and October 1st 2005 were included. The children were divided into two groups: a historical group, composed of children hospitalized between January 1st and December 31st 2004, treated with conventional thoracotomy before day 8 of chest drain placement and a prospective group, composed of children hospitalized between January 1st and October 1st 2005, treated with intrapleural STK before day 8 of chest drain placement. The variables used to compare outcome and treatment complications were duration of chest tube drainage after the treatment procedure, complications, re-admission, length of hospital stay, and death.

RESULTS

The results in both groups were similar. Length of hospital stay showed no significant differences. Duration of chest tube drainage after intrapleural STK was significantly shorter than after thoracotomy (p < 0.001). In the thoracotomy group a significantly higher proportion of patients required partial atypical pneumonectomy (p = 0.051). There were no deaths.

CONCLUSIONS

Intrapleural STK is a valid alternative for the treatment of children with complicated parapneumonic empyema.

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.

Successful thoracoscopic treatment of severe bilateral empyema in an infant

We report a case of rapid progression of bilateral pyothorax exacerbated by viral influenza in an infant. The patient, an 11-month-old girl, was diagnosed with viral influenza, and oseltamivir phosphate was administered. However, after only 4 days the influenza was followed by rapid progression of methicillin-susceptible Staphylococcus aureus (MSSA) pneumonia and pyothorax, resulting in disseminated intravascular coagulation. Because thoracentesis and antibiotics could not control the pyothorax, a serious condition, we performed bilateral video-assisted thoracoscopic decortication on the eighth hospital day. She recovered with excellent lung expansion and was discharged on the 37th hospital day.

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.

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.

Comparison of Urokinase and Video-assisted Thoracoscopic Surgery for Treatment of Childhood Empyema

BACKGROUND

Despite increasing incidence and morbidity, little evidence exists to inform the best management approach in childhood empyema.

AIM

To compare chest drain with intrapleural urokinase and primary video-assisted thoracoscopic surgery (VATS) for the treatment of childhood empyema.

METHODS

Children were prospectively randomized to receive either percutaneous chest drain with intrapleural urokinase or primary VATS. The primary outcome was the number of hospital days after intervention. Secondary end points were number of chest drain days, total hospital stay, failure rate, radiologic outcome at 6 mo, and total treatment costs.

RESULTS

Sixty children were recruited. The two groups were well matched for demographics; baseline characteristics; and hematologic, biochemical, and bacteriologic parameters. No significant difference was found in length of hospital stay after intervention between the two groups: VATS (median [range], 6 [3-16] d) versus urokinase (6 [4-25] d) (p = 0.311; 95% confidence interval, -2 to 1). No difference was demonstrated in total hospital stay: VATS versus urokinase (8 [4-17] d and 7 [4-25] d) (p = 0.645); failure rate: 5 (16.6%); and radiologic outcome at 6 mo after intervention in both groups. The mean (median) treatment costs of patients in the urokinase arm US dollars 9,127 (US dollars 6,914) were significantly lower than those for the VATS arm US dollars 11,379 (US dollars 10,146) (p < 0.001).

CONCLUSIONS

There is no difference in clinical outcome between intrapleural urokinase and VATS for the treatment of childhood empyema. Urokinase is a more economic treatment option compared with VATS and should be the primary treatment of choice. This study provides an evidence base to guide the management of childhood empyema.

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.

Conservative use of chest-tube insertion in children with pleural effusion

The aim of this work was to evaluate the effect of a more conservative use of chest-tube insertion on the short-term and long-term outcome of pleural infection. Sixty-five patients with pleural infection, aged 1 month to 16 years were each treated according to one of the two protocols: classical management with chest-tube insertion (classical group, n = 33), or conservative use of chest-tube insertion (conservative group, n = 32), with drainage indicated only in the case of voluminous pleural effusion defined by a mediastinal shift and respiratory distress and/or an uncontrolled septic situation. The two groups were comparable with regard to age, baseline C-reactive protein (CRP) value and white blood cell counts, pleural thickness, identified bacteria, and antibiotic treatment. Chest-tube insertion was performed in 17 patients (52%) of the classical group compared to eight patients (25%) of the conservative group (P = 0.03). Duration of temperature above 39 degrees C was shorter in the conservative group (10 +/- 1 vs. 14 +/- 1 days, P = 0.01), as was the normalization of CRP (13 +/- 1 vs. 17 +/- 1 days, P = 0.03). Duration of hospitalization and intravenous (IV) antibiotherapy as well as the delay of chest-radiograph normalization was not significantly different between the two groups. A more conservative use of chest-tube insertion did not change short- and long-term outcome of the pleural infection in children. Drainage could be restricted to the most severely affected patients with pleural empyema causing a mediastinal shift and respiratory distress and/or presenting with an uncontrolled septic situation.

Scoring system for empyema thoracis and help in management

OBJECTIVE

To evaluate the implications of a newly defined severity scoring of empyema in children for the prediction of surgical management and to compare the length of hospitalization as an outcome measure of patients treated using medical therapy, salvage video-assisted thoracoscopic surgery (VATS) vs early elective VATS.

METHODS

A retrospective chart review of parapneumonic empyema of patients below 18 years of age admitted to a tertiary children's hospital in northern Taiwan from April 1993 to December 2002 was performed. Patients were categorized into a medical group who received antibiotic therapy, needle aspirations with/without tube thoracostomy; a salvage VATS group when the patients required surgery for the relief of persistent fever > 38 degrees C, chest pains or dyspneic respirations despite initial medical therapy; an early VATS group when the patients received elective surgery early after admission. The demographic data, clinical features, laboratory findings, and duration of hospitalization were compared using a severity score of empyema (SSE).

RESULTS

Streptococcus pneumoniae was the most common infecting organism, followed by Staphylococcus aureus, Pseudomonas aeruginosa. No organisms were recovered in 39% of patients. A pleural pH < 7.1 increases the odds of requiring surgical intervention by 6 times among this cohort. Children who required decortication of empyema had a higher severity score (mean 4.8 vs 3.0, p < 0.005). The duration of hospitalization for patients having early VATS showed a shortening stay (mean 18 vs 28 days) as compared to salvage VATS.

CONCLUSION

A pleural pH < 7.1 and a newly designed clinical severity score of empyema 4 are two predictors of surgical intervention for fibrinopurulent empyema in the present study. Early elective VATS may be adopted not later than 7 days after failure of appropriate antibiotic therapy and adequate drainage of empyema to decrease the length of stay and minimize morbidity.

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.

Medical management of parapneumonic pleural disease

Considerable heterogeneity exists in the management of parapneumonic pleural disease. A randomized controlled trial (RCT) demonstrated the effectiveness of small-catheter drainage with fibrinolysis, but surgical devotees suggest this may only be applicable to "early" cases. We examined evidence-based medical management in "all-comers." We performed a retrospective database analysis of the management of all children with complex pleural effusion admitted to the John Radcliffe Hospital over the 7-year period 1996-2003. One hundred and ten children were admitted. Ten were excluded as they were part of a multicenter RCT and had received intrapleural saline instead of urokinase. Of the remaining 100, 51 were female and 49 male. Median age on admission was 5.8 years (range, 0.3-16.5). Symptoms preadmission averaged 11 days, with December the most common month for presentation. Ninety-six underwent chest ultrasound, confirming an effusion in all, described as loculated/septated (68) or echogenic (11). In 17 cases, no specific comment was made regarding the nature of the fluid seen on ultrasound. Ninety-five had subsequent chest tube drainage and then received intrapleural fibrinolysis with urokinase. An etiological organism was identified in 21 cases (21%) (Streptococcus pneumoniae in 10, group A Streptococcus in 5, Staphylococcus aureus in 4, Haemophilus influenzae in 1, and coliform in 1). In a further 9 cases (9%), Gram-positive organisms were seen on pleural fluid microscopy, but did not grow on culture. Two (2%) required surgery due to the persistence of symptoms and an inadequate response to medical management. Median duration of admission was 7 days (range, 2-21 days); median duration of stay from intervention was 5 days (range, 2-19 days). At median follow-up of 8 weeks (range, 3-20 weeks), all children were symptom-free, with minimal pleural thickening on chest X-ray. In conclusion, antibiotic therapy with chest drain insertion and intrapleural urokinase is effective in treating complex parapneumonic effusion and is associated with a good long-term outcome.

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.

The changing face of pleural empyemas in children: epidemiology and management

OBJECTIVE

Empyema remains a significant cause of morbidity in children. This study evaluates the changes that have affected the outcome in children with pleural empyema, including the emergence of resistant organisms, the introduction of the pneumococcal conjugate vaccine, and earlier treatment with video-assisted thoracoscopy (VATS).

METHODS

A retrospective chart review was performed on all patients who were discharged with a diagnosis of empyema and community-acquired pneumonia over a 10-year period (1993-2002) at Texas Children's Hospital in Houston, Texas. Data collected included demographic information, clinical presentation, radiographic studies, laboratory data including culture results, and hospital course.

RESULTS

A total of 230 charts were available for review. The mean age of the patients was 4.0 +/- 3.6 years. Of the pleural fluid cultures performed, 32% (69 of 219) were positive. An additional 27 patients had a cause identified by blood culture. The first penicillin-nonsusceptible Streptococcus pneumoniae was identified in 1995, and the first methicillin-resistant Staphylococcus aureus was identified in 1998. After the universal use of the pneumococcal conjugate vaccine, 3 major changes have occurred (1999-2000 vs 2001-2002): 1) the number of patients admitted with empyema (per 10 000 admissions) has decreased from 23 to 12.6; 2) the prevalence of S pneumoniae has decreased from 66% (29 of 44) to 27% (4 of 15); and 3) S aureus has become the most common pathogen isolated (18% vs 60%), with 78% of those being methicillin resistant. The use of early VATS (<48 hours after admission) versus late VATS (>48 hours after admission) significantly decreased the length of hospitalization (11.49 +/- 6.56 days vs 15.18 +/- 8.62 days).

CONCLUSIONS

The microbiologic cause of empyema has changed with an increasing incidence of S aureus, particularly methicillin-resistant S aureus. The use of VATS for initial therapy of empyema results in decreased duration of fever and length of hospitalization.

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.

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

BACKGROUND

The incidence of pediatric postpneumonic empyema increases, and there is little consensus on its management. Open thoracotomy has been linked with high morbidity and prolonged hospitalization. Our aim was to review the outcome after open thoracotomy and to provide a set of data for comparison with other treatment modalities.

METHODS

Forty-four children (median age, 8 years, 2 months to 16 years) undergoing surgery for postpneumonic empyema between 1993 and 2002 in our unit were studied.

RESULTS

The median time from onset of symptoms to admission in a pediatric unit was 8 days (range, 2 to 63 days), the median time from pediatric admission to surgical referral was 3 days (range, 0 to 19 days), and the median time from surgical admission to thoracotomy was 1 day (range, 0 to 2 days). Eight children had a chest drain before surgical admission. Six patients, who were referred late (19 to 69 days), had lung abscesses. A limited muscle sparing thoracotomy (44 patients), formal decortication (36 patients), lung debridement (5 patients), and lobectomy (1 patient) were performed. After thoracotomy, median time to apyrexia was 1 day (range, 0 to 27 days) and drain removal was 3 days (range, 1 to 16 days). A pathogen was isolated in 21 patients. There were no deaths. Four children with abscesses remained septic and had lobectomies (2 patients) and debridements (2 patients). The median postoperative hospital stay was 5 to 53 days. One child had postpneumonic empyema develop and had decortication 3 months postoperatively. At follow-up, all children were doing well and had satisfactory radiographs. The Kaplan-Meier 5-year and 10-year survival rate, freedom from any reoperation, and freedom from hospital readmission were 100%, 87%, and 98%, respectively.

CONCLUSIONS

Open thoracotomy remains an excellent option for management of stage II-III empyema in children. When open thoracotomy is performed in a timely manner there is low morbidity and it provides rapid resolution of symptoms with a short hospital stay. However, delayed referrals may result in advanced pulmonary sepsis and a protracted clinical course. The late results are encouraging. Use of thoracoscopy or fibrinolysis should be considered on the basis of their own merit, not on the assumption of probable adverse outcomes after thoracotomy.

Alteplase in the treatment of complicated parapneumonic effusion: a case report

The treatment of complex parapneumonic effusions in children remains controversial, with some advocating less invasive, strictly medical management and others supporting a more aggressive approach of thoracotomy with or without decortication. Recent advances, including video-assisted thoracoscopic surgery and intrapleural fibrinolytic therapy, offer new options for effective treatment. We report the first case of successful resolution of a complex parapneumonic effusion in a 16-month-old girl with the use of tissue plasminogen activator (alteplase), infused via a catheter in the pleural space.

Outcomes of primary image-guided drainage of parapneumonic effusions in children

OBJECTIVE

To assess the outcome of image-guided needle aspiration when compared with image-guided percutaneous catheter drainage in the management of parapneumonic effusions in children.

METHODS

A retrospective chart review was conducted of the medical records, microbiology, and radiology reports of 67 children who presented with parapneumonic effusions and underwent primary image-guided drainage between April 1, 1995, and April 1, 2000.

RESULTS

Thirty-four patients had aspiration only, and 33 patients had pigtail catheters placed. The 2 drainage methods had similar median length of stay and complication rates. The reintervention rate in this study was 27% (18 patients). Children who underwent primary aspiration without catheter placement had significantly higher rates of reintervention. Method of drainage, pH lower than 7.2, and loculation of the fluid collection were independent predictors of reintervention. A low glucose level was an additive predictor of reintervention when the pH was low.

CONCLUSIONS

Aspiration and catheter drainage of parapneumonic effusions had similar complication rates and lengths of stay, but children who underwent primary aspiration had significantly higher reintervention rates, particularly when pH and glucose levels were low. Therefore, primary catheter placement for parapneumonic effusions should be considered in children who undergo diagnostic thoracentesis. The decision regarding tube placement could be facilitated by the on-site availability of a pH meter and a glucometer.

Empyema: development of a critical pathway

Over the past 20 years at the authors' institution, the management of empyema has evolved. The authors recently have developed a critical pathway in an effort to facilitate diagnosis, guide therapy, and reduce cost. Currently, the average length of stay using this pathway is 4 to 5 days with decreased cost compared to the historic length of stay and a national children's hospital database. The authors review steps to develop a critical pathway as well as discuss their pathway for empyema management.

Radiological perspectives in empyema

Empyema is a common cause for hospital admission in children. For years, clinicians have relied on chest X-rays to aid diagnosis and monitor treatment. New imaging techniques, particularly ultrasound, have helped in planning the management of children with empyema. Other cross-sectional radiological investigations are useful in a small proportion of children with complicated disease. The mainstays of imaging in the vast majority of children with empyema are chest radiography and ultrasound.

Reducing the trauma of congenital heart surgery

While describing the circulatory system in De Moto Cordis, in 1628, William Harvey developed precepts for investigation, which could be modified slightly to guide the adoption of new technology and technique in the twenty-first century. Harvey might suggest (1) careful and accurate observation and description of a new technique, (2) a tentative explanation of how the technique improves on existing techniques, (3) a controlled testing of the hypothesis, and (4) conclusions based on the results of the experiments. Also, he might admonish surgery today, with its massively enhanced capabilities for information management, to rigorously test the validity of these conclusions with quantitative reasoning. In the future, precise measurement of the "trauma" of surgery, or even an individual surgeon, may be possible, and the long-term impact of a chest wall incision on a patient's self-esteem may be predictable. Absent such objective measures, justifications for "minimally invasive" deviations from conventional technique in surgery for CHD lack substance. Morbidity, mortality, and physiological endpoints will continue to form the foundation for therapeutic plans; however, the potential for emerging technology to reduce the trauma of these plans remains tantalizing.