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Bell ACJ, Baker C, Duret A. Is chest drain insertion and fibrinolysis therapy equivalent to video-assisted thoracoscopic surgery to treat children with parapneumonic effusions? Arch Dis Child 2023; 108:940-942. [PMID: 37722762 DOI: 10.1136/archdischild-2023-325908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 09/05/2023] [Indexed: 09/20/2023]
Affiliation(s)
- Aaron Colin John Bell
- Department of Paediatric Infectious Diseases, St Mary's Hospital, Imperial College NHS Healthcare Trust, London, UK
| | - Camilla Baker
- Department of Paediatric Infectious Diseases, St Mary's Hospital, Imperial College NHS Healthcare Trust, London, UK
| | - Amedine Duret
- Department of Paediatric Infectious Diseases, St Mary's Hospital, Imperial College NHS Healthcare Trust, London, UK
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2
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Fernandez Elviro C, Longcroft-Harris B, Allin E, Leache L, Woo K, Bone JN, Pawliuk C, Tarabishi J, Carwana M, Wright M, Nama N. Conservative and Surgical Modalities in the Management of Pediatric Parapneumonic Effusion and Empyema: A Living Systematic Review and Network Meta-Analysis. Chest 2023; 164:1125-1138. [PMID: 37463660 DOI: 10.1016/j.chest.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 04/08/2023] [Accepted: 06/08/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND The optimal treatment for community-acquired childhood pneumonia complicated by empyema remains unclear. RESEARCH QUESTION In children with parapneumonic effusion or empyema, do hospital length of stay and other key clinical outcomes differ according to the treatment modality used? STUDY DESIGN AND METHODS A living systematic review of randomized controlled trials (RCTs) was conducted by searching the Cochrane Central Register of Controlled Trials, Embase, Latin American and Caribbean Health Sciences Literature, Ovid MEDLINE, and Web of Science Core Collection databases. Eligible RCTs included patients aged < 18 years and compared two of the following treatment modalities: antibiotics alone, chest tube insertion with or without fibrinolytics, video-assisted thoracoscopic surgery (VATS), and decortication via thoracotomy. A network meta-analysis was performed to evaluate treatment effects on hospital length of stay (LOS), the primary outcome. RESULTS Eleven trials including a total of 590 patients were selected for the network meta-analysis. Compared with a chest tube alone, a chest tube with fibrinolytics, thoracotomy, and VATS were all associated with shorter LOS, with a mean difference of 5.05 days (95% CI, 2.46-7.64), 6.33 days (95% CI, 3.17-9.50), and 5.86 days (95% CI, 3.38-8.35), respectively. No substantial differences in LOS were observed between the latter three interventions. None of the 11 RCTs compared antibiotics alone vs other types of treatment. Most trials reported peri-procedural complications and the need for reintervention, but the descriptions differed significantly between trials, preventing meta-analysis. In trials reporting health care-associated costs, fibrinolytics had cost advantages compared with VATS. Short- and long-term morbidity and mortality were very low, regardless of the treatment modality. INTERPRETATION The results of this network meta-analysis showed that a chest tube alone was associated with a longer LOS compared with other treatment modalities. The lower cost associated with a chest tube plus fibrinolytics warrants consideration when choosing between treatment options, given similar LOS and clinical outcomes compared with the other modalities.
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Affiliation(s)
- Clara Fernandez Elviro
- Division of Respiratory Medicine, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, BC, Canada; Department Woman-Mother-Child, Service of Paediatrics, Paediatric Pulmonology and Cystic Fibrosis Unit, University Hospital of Lausanne and Faculty of Biology and Medicine, University of Lausanne, Switzerland
| | | | - Emily Allin
- Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Leire Leache
- Unit of Innovation and Organization, Navarre Institute for Health Research (IdiSNA), Pamplona, Spain
| | - Kellan Woo
- Vancouver-Fraser Medical Program, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jeffrey N Bone
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Colleen Pawliuk
- British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Jalal Tarabishi
- Department of Biological Sciences, Faculty of Science, University of Alberta, Edmonton, AB, Canada
| | - Matthew Carwana
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; British Columbia Children's Hospital Research Institute, Vancouver, BC, Canada; Division of General Pediatrics, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Marie Wright
- Division of Respiratory Medicine, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, BC, Canada; Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Nassr Nama
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, WA.
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3
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Haggie S, Selvadurai H, Gunasekera H, Fitzgerald DA, Lord D, Chennapragada MS. Pediatric empyema: Are ultrasound characteristics at the time of intervention predictive of reintervention? Pediatr Pulmonol 2022; 57:1643-1650. [PMID: 35438254 DOI: 10.1002/ppul.25931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 03/30/2022] [Accepted: 04/17/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Parapneumonic effusions and empyema are the most frequent complication of pediatric pneumonia. Interventions include chest drain and fibrinolytics (CDF) or thoracoscopic surgery. CDF is considered less invasive, and more cost-effective though with higher rates of reintervention. We hypothesized that sonographic pleural fluid characteristics could identify cases at increased risk of reintervention following primary CDF. METHODS A retrospective cohort of complicated pneumonia managed with primary CDF (2011-2018). Cases were reviewed using ultrasound criteria to describe pleural fluid. We analyzed the correlation between ultrasound findings and reintervention. RESULTS We report 129 cases with a median age of 3.8 years and 44% female. A repeat intervention occurred for 24/129 (19%) cases. The interobserver reliability was moderate for the number of septations (κ 0.72, 95% CI [confidence interval]: 0.62-0.81), weak for the size of the largest locule (κ 0.55, 95% CI: 0.44-0.67), and minimal for the level of echogenicity (κ 0.24, 95% CI: 0.11-0.37), pleural thickening (κ 0.29, 95% CI: 0.17-0.42), maximum effusion depth (κ 0.37, 95% CI: 0.22-0.51), and radiologist's risk for reintervention (κ 0.34, 95% CI: 0.18-0.5). A repeat intervention was not associated with any objective sonographic variable. CONCLUSION We report no association between ultrasound characteristics and repeat intervention for complicated pneumonia following primary CDF treatment. There was minimal interobserver agreement in reporting ultrasound characteristics despite more objective criteria. Clinicians rely on ultrasound findings to support decisions around intervention in pediatric empyema. This study does not support relying on ultrasound to estimate the likelihood of reintervention.
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Affiliation(s)
- Stuart Haggie
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Hiran Selvadurai
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Hasantha Gunasekera
- Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Dominic A Fitzgerald
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - David Lord
- Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Paediatric Interventional Radiology, Division of Medical Imaging, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Murthy S Chennapragada
- Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Paediatric Interventional Radiology, Division of Medical Imaging, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
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4
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Federici S, Bédat B, Hayau J, Gonzalez M, Triponez F, Krueger T, Karenovics W, Perentes JY. Outcome of parapneumonic empyema managed surgically or by fibrinolysis: a multicenter study. J Thorac Dis 2022; 13:6381-6389. [PMID: 34992818 PMCID: PMC8662487 DOI: 10.21037/jtd-21-1083] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 09/16/2021] [Indexed: 11/21/2022]
Abstract
Background Parapneumonic empyema (PPE) management remains debated. Here we present the outcome of a comparable population with PPE treated over a 4-year period in two Thoracic Surgery University Centers with different approaches: one with an early “surgical” and the other with a “fibrinolytic” approach. Methods All operable patients with PPE managed in both centers between January 2014 and January 2018 were reviewed. Patients with persistent pleural effusion/loculations following drainage were managed by a “surgical” approach in one center and by “fibrinolytic” approach in the other. For each patient, we recorded the age, sex, hospital stay, morbidity/mortality and change in pleural opacity on chest X-ray before and at the end of the treatment. Results During the study period, 66 and 93 patients underwent PPE management in the “surgical” and “fibrinolytic” centers respectively. The population characteristics were comparable. Infection was controlled in all patients. In the “fibrinolytic” group, 20 patients (21.5%) underwent an additional drain placement while 12 patients (12.9%) required surgery to correct PPE. In the “surgical” group, 4 patients (6.1%) developed postoperative arrhythmia while 2 patients (3%) underwent a second surgery to evacuate a hemothorax. Median drainage {3 [2–4] vs. 5 [4–7] days} and hospital {7 [5–10] vs. 11 [7–19] days} durations were significantly lower in the “surgical” compared to the “fibrinolytic” center. Pleural opacity regression with therapy was significantly more important in the “surgical” compared to the “fibrinolytic” group (−22%±18% vs. −16%±17%, P=0.035). Conclusions Surgical management of PPE was associated with shorter chest tube and hospital duration and better pleural space control. Prospective randomized studies are mandatory.
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Affiliation(s)
- Sara Federici
- Division of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.,University Center of Thoracic Surgery of Western Switzerland, Switzerland
| | - Benoit Bédat
- University Center of Thoracic Surgery of Western Switzerland, Switzerland.,Division of Thoracic and Endocrine Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - Justine Hayau
- Division of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.,University Center of Thoracic Surgery of Western Switzerland, Switzerland
| | - Michel Gonzalez
- Division of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.,University Center of Thoracic Surgery of Western Switzerland, Switzerland
| | - Frederic Triponez
- University Center of Thoracic Surgery of Western Switzerland, Switzerland.,Division of Thoracic and Endocrine Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - Thorsten Krueger
- Division of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.,University Center of Thoracic Surgery of Western Switzerland, Switzerland
| | - Wolfram Karenovics
- University Center of Thoracic Surgery of Western Switzerland, Switzerland.,Division of Thoracic and Endocrine Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - Jean Y Perentes
- Division of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.,University Center of Thoracic Surgery of Western Switzerland, Switzerland
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5
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Wu YH, Wang JL, Wang MS. Factors Associated With the Presence of Tuberculous Empyema in Children With Pleural Tuberculosis. Front Pediatr 2021; 9:751386. [PMID: 34778142 PMCID: PMC8585973 DOI: 10.3389/fped.2021.751386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 09/27/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Until now, the factor of tuberculous empyema (TE) in children with pleural tuberculosis (TB) remains unclear. Therefore, a retrospective study was conducted to assess the factors associated with the presence of TE in children. Methods: Between January 2006 and December 2019, consecutive children patients (≤ 15 years old) with suspected pleural TB were selected for further analysis. Empyema was defined as grossly purulent pleural fluid. The demographic, clinical, laboratory, and radiographic features were collected from the electrical medical records retrospectively. Univariate and multivariate logistic regressions were used to explore the factors associated with the presence of TE 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 TE (n = 27) and Non-TE (n = 127) groups. Multivariate analysis revealed that surgical treatment (age- and sex-adjusted OR = 92.0, 95% CI: 11.7, 721.3), cavity (age- and sex-adjusted OR = 39.2, 95% CI: 3.2, 476.3), pleural LDH (>941 U/L, age- and sex-adjusted OR = 14.8, 95% CI: 2.4, 90.4), and temperature (>37.2°C, age- and sex-adjusted OR = 0.08, 95% CI: 0.01, 0.53) were associated with the presence of TE in children with pleural TB. Conclusion: Early detection of the presence of TE in children remains a challenge and several characteristics, such as surgical treatment, lung cavitation, high pleural LDH level, and low temperature, were identified as factors of the presence of TE in children with pleural TB. These findings may improve the management of childhood TE.
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Affiliation(s)
- Yan-Hua Wu
- Department of Lab Medicine, Shandong Provincial Chest Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Department of Lab Medicine, Shandong Public Health Clinical Center, Shandong University, Jinan, China
| | - Jun-Li Wang
- Department of Lab Medicine, The Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, China
| | - Mao-Shui Wang
- Department of Lab Medicine, Shandong Provincial Chest Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Department of Lab Medicine, Shandong Public Health Clinical Center, Shandong University, Jinan, China.,Shandong Key Laboratory of Infectious Respiratory Disease, Jinan, China
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6
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Pediatric empyemas - Has the pendulum swung too far? J Pediatr Surg 2020; 55:2356-2361. [PMID: 31973927 DOI: 10.1016/j.jpedsurg.2019.12.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 12/05/2019] [Accepted: 12/21/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND The management of childhood empyemas has transformed over the past decade, with current trends favoring chest tube placement and intrapleural fibrinolytic therapy. Although this strategy often avoids the need for video-assisted thoracoscopic surgery (VATS), hospital length of stay can be long. METHODS To characterize national trends and outcomes associated with empyema management, the Pediatric Health Information System (PHIS) database was queried to identify children (2 months-18 years) treated for an empyema between January 2010 and December 2017. The cohort was divided into those treated with primary VATS and those treated with chest tube and intrapleural fibrinolysis. Number of chest radiographic studies obtained, frequency of pediatric intensive care unit (PICU) admission, mechanical ventilation requirements, and length of hospitalization were compared between groups. RESULTS A total of 3,365 otherwise healthy children met inclusion criteria. Among them, 523 (16%) were managed with primary VATS and 2,842 (84%) were managed with chest tube and fibrinolytic therapy. Of those who were treated with chest tube and fibrinolysis, 193 (6.8%) subsequently underwent VATS. The percentage of children treated with chest tube and fibrinolysis increased from 65% in 2010 to 95% in 2017 (p<0.001). After adjusting for age, race, ethnicity, payer, and region, children who underwent primary VATS received fewer chest radiographic studies, were less likely to be admitted to the PICU or require mechanical ventilation and had a shorter PICU and hospital length of stay compared to those who were treated with chest tube and fibrinolytic therapy (p<0.001 for all analyses). DISCUSSION Although national trends favor chest tube and fibrinolysis, primary VATS are associated with a shorter hospital and PICU length of stay and a lower requirement for mechanical ventilation. Future studies should aim to risk stratify children who may suffer from a protracted course with the goal to offer primary VATS to this subset of children and return them to normal life more expeditiously. LEVEL OF EVIDENCE III.
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7
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Oyetunji TA, Dorman RM, Svetanoff WJ, Depala K, Jain S, Dekonenko C, St Peter SD. Declining frequency of thoracoscopic decortication for empyema - redefining failure after fibrinolysis. J Pediatr Surg 2020; 55:2352-2355. [PMID: 31983399 DOI: 10.1016/j.jpedsurg.2019.12.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 12/23/2019] [Accepted: 12/26/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Primary fibrinolysis for pediatric empyema has become standard of care at our institution. Early study of our protocol revealed a 16% thoracoscopic decortication rate after primary fibrinolysis. We now report the frequency with which children progress to operation with maturation of the protocol. METHODS A database of patients diagnosed with empyema between September 2014 and March 2019 was examined. Patients who underwent tissue plasminogen activator (tPA) therapy with or without subsequent video-assisted thoracoscopic (VATS) decortication were included. Patients with additional indications for tube thoracostomy or VATS were excluded. RESULTS Forty-eight patients were included. Median age was 4.5 years [IQR 2-9.3]. Median length of stay (LOS) was 8 days [IQR 6-11]. No patients underwent primary VATS. Median days with a chest tube was 5 [IQR 5-6] and median number of doses of tPA was 3 [IQR 3-3]. Seven patients (14.6%) had a chest tube replaced without undergoing VATS. The VATS rate was 4.2% in the first half of this study but 0% in the last 33 months. CONCLUSION Thoracoscopic decortication is rarely necessary in children with empyema. Raising the threshold for surgical intervention and utilizing further nonoperative measures can avoid an operation in most children without increasing in-hospital length of stay. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Tolulope A Oyetunji
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, USA; School of Medicine, University of Missouri-Kansas City, 2411 Holmes St, Kansas City, MO 64108, USA
| | - Robert M Dorman
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Wendy Jo Svetanoff
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Kartik Depala
- School of Medicine, University of Missouri-Kansas City, 2411 Holmes St, Kansas City, MO 64108, USA
| | - Shubhika Jain
- School of Medicine, University of Missouri-Kansas City, 2411 Holmes St, Kansas City, MO 64108, USA
| | - Charlene Dekonenko
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, USA; School of Medicine, University of Missouri-Kansas City, 2411 Holmes St, Kansas City, MO 64108, USA.
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8
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Buonsenso D, Tomà P, Scateni S, Curatola A, Morello R, Valentini P, Ferro V, D'Andrea ML, Pirozzi N, Musolino AM. Lung ultrasound findings in pediatric community-acquired pneumonia requiring surgical procedures: a two-center prospective study. Pediatr Radiol 2020; 50:1560-1569. [PMID: 32821992 DOI: 10.1007/s00247-020-04750-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 04/14/2020] [Accepted: 06/02/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Lung ultrasound (US) in the evaluation of suspected pediatric pneumonia is increasingly used and has a recognized role in evaluating pleural effusions, although there are no detailed studies specifically addressing its use in the pediatric population. OBJECTIVES To define lung US findings of severe pediatric community-acquired pneumonia that required surgical procedures during admission. MATERIALS AND METHODS Our prospective case-control study compared lung US findings in patients ages 1 month to 17 years admitted with community-acquired pneumonia that required surgical procedures from findings those who did not. Lung US was performed at admission and always before surgical procedures. Medical treatment, laboratory and microbiological findings, chest X-ray, computed tomography scan and surgical procedures are described. RESULTS One hundred twenty-one children with community-acquired pneumonia were included; of these, 23 underwent surgical intervention. Compared with the control group, children requiring a surgical procedure had a significantly higher rate of large consolidations (52.2%; 95% confidence interval [CI]: 30.6% to 73.2%), larger and complicated pleural effusions (100%; 95% CI: 85.2% to 100%), and both liquid and air bronchograms (73.9%; 95% CI: 51.6% to 89.8%). CONCLUSION Larger consolidations, larger and more complicated pleural effusions, and liquid and air bronchograms were associated with surgical treatment.
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Affiliation(s)
- Danilo Buonsenso
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
- Istituto di Microbiologia, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Paolo Tomà
- Department of Radiology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Simona Scateni
- Emergency Department, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Antonietta Curatola
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Rosa Morello
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Piero Valentini
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Pediatrics, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Valentina Ferro
- Emergency Department, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | | | - Nicola Pirozzi
- Emergency Department, Ospedale Pediatrico Bambino Gesù, Rome, Italy
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9
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Thoracoscopic debridement for empyema thoracis. J Pediatr Surg 2020; 55:2187-2190. [PMID: 32147236 DOI: 10.1016/j.jpedsurg.2020.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 12/27/2019] [Accepted: 02/05/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND/PURPOSE The success rate of early thoracoscopic debridement (TD) for childhood empyema was reviewed in light of the increasing reported incidence of empyema associated with pulmonary necrosis (PN). METHODS Data were collected from 106 patients who underwent thoracoscopic intervention from 2010 to 2016. Twenty additional patients with severe PN/Bronchopleural Fistula (BPF) were not suitable for TD requiring thoracotomy and Serratus anterior digitation flap. RESULTS 106 patients with a median age of 4 years (IQR 2-6 years) were considered for TD as primary intervention of which 3 needed conversion to thoracotomy. TD alone was successful in 93/106 however, 10 patients required subsequent minithoracotomy for PN/BPF (managed with Serratus anterior digitation flap). Counting conversions as failure, the overall success rate of TD was 88%. No statistical difference was demonstrable in success rate compared to our previous series (93% (106/114) vs 88% (93/106)). CONCLUSIONS Primary TD in pediatric empyema is associated with an excellent outcome achieving adequate drainage and full expansion of the lung. The majority of failures in our series were attributable to PN/BPF, requiring thoracotomy and Serratus anterior digitation flap. This is likely a consequence of the increasing incidence of necrotizing pneumonia. LEVEL OF EVIDENCE Level IV.
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10
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Haggie S, Gunasekera H, Pandit C, Selvadurai H, Robinson P, Fitzgerald DA. Paediatric empyema: worsening disease severity and challenges identifying patients at increased risk of repeat intervention. Arch Dis Child 2020; 105:886-890. [PMID: 32209557 DOI: 10.1136/archdischild-2019-318219] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 02/06/2020] [Accepted: 03/08/2020] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Empyema is the most common complication of pneumonia. Primary interventions include chest drainage and fibrinolytic therapy (CDF) or video-assisted thoracoscopic surgery (VATS). We describe disease trends, clinical outcomes and factors associated with reintervention. DESIGN/SETTING/PATIENTS Retrospective cohort of paediatric empyema cases requiring drainage or surgical intervention, 2011-2018, admitted to a large Australian tertiary children's hospital. RESULTS During the study, the incidence of empyema increased from 1.7/1000 to 7.1/1000 admissions (p<0.001). We describe 192 cases (174 CDF and 18 VATS), median age 3.0 years (IQR 1-5), mean fever duration prior to intervention 6.2 days (SD ±3.3 days) and 50 (26%) cases admitted to PICU. PICU admission increased during the study from 18% to 34% (p<0.001). Bacteraemia occurred in 23/192 (12%) cases. A pathogen was detected in 131/192 (68%); Streptococcus pneumoniae 75/192 (39%), S. aureus 25/192 (13%) and group A streptococcus 13/192 (7%). Reintervention occurred in 49/174 (28%) and 1/18 (6%) following primary CDF and VATS. Comparing repeat intervention with single intervention cases, a continued fever postintervention increased the likelihood for a repeat intervention (OR 1.3 per day febrile; 95% CI 1.2 to 1.4, p<0.0001). Younger age, prolonged fever preintervention and previous antibiotic treatment were not associated with initial treatment failure (all p>0.05). CONCLUSION We report increasing incidence and severity of empyema in a large tertiary hospital. One in four patients required a repeat intervention after CDF. Neither clinical variables at presentation nor early investigations were able to predict initial treatment failure.
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Affiliation(s)
- Stuart Haggie
- Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Hasantha Gunasekera
- Department of Discipline of Paediatrics and Child Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Chetan Pandit
- Department of Respiratory Medicine, Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Hiran Selvadurai
- Department of Respiratory Medicine, Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Paul Robinson
- Department of Respiratory Medicine, Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Dominic A Fitzgerald
- Department of Respiratory Medicine, Children's Hospital at Westmead, Sydney, New South Wales, Australia
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11
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Do H, Nguyen Q, Nguyen L, Nguyen L. Single Trocar Thoracoscopic Surgery for Pleural Empyema in Children. J Laparoendosc Adv Surg Tech A 2020. [PMID: 32326810 DOI: 10.1089/lap.2019.0637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Hung Do
- Urological Department and General Surgical Department, National Children's Hospital, Hanoi, Vietnam
| | - Quang Nguyen
- Urological Department and General Surgical Department, National Children's Hospital, Hanoi, Vietnam
| | - Liem Nguyen
- Pediatric Surgical Department, Vinmec International Hospital, Hanoi, Vietnam
| | - Linh Nguyen
- Urological Department and General Surgical Department, National Children's Hospital, Hanoi, Vietnam
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Haggie S, Fitzgerald DA, Pandit C, Selvadurai H, Robinson P, Gunasekera H, Britton P. Increasing Rates of Pediatric Empyema and Disease Severity With Predominance of Serotype 3 S. pneumonia: An Australian Single-center, Retrospective Cohort 2011 to 2018. Pediatr Infect Dis J 2019; 38:e320-e325. [PMID: 31634299 DOI: 10.1097/inf.0000000000002474] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND The impact of universal 13-valent pneumococcal conjugate vaccine immunization on pediatric empyema rates and pathogens in Australia is not known. We aimed to describe empyema epidemiology, clinical characteristics and treatment during an 8-year period. METHODS A retrospective study between 2011 and 2018 of empyema cases admitted to a large pediatric referral hospital, for management with either pleural drainage and fibrinolytics or surgical intervention. RESULTS There were 195 cases in 8 years. Empyema incidence and ICU admission rates significantly increased during the study with a peak incidence of 7.1/1000 medical admissions in 2016 (χ for trend of incidence 37.8, P < 0.001 and for ICU admissions 15.3, P < 0.001). S. pneumoniae was the most common pathogen (75/195, 39%) with serotype 3 the most detected (27/75: 27%). S. pyogenes compared with S. pneumoniae had significantly fewer days of fever before admission (3.9 vs. 6.4, mean difference 2.4, 95% CI: 0.84-4.08, P = 0.003) and higher proportion requiring direct ICU admission (6/75; 8% vs. 7/15; 47%, P < 0.001). Compared with S. pneumoniae, cases with no pathogen detected by culture or PCR had fewer days of fever post intervention (4.4 vs. 7.4 days, mean difference 2.7 days, P = 0.002). S. aureus occurred more commonly in infants (10/25; 40% vs. 1/75; 1%, P < 0.001) and children of indigenous background (5/25; 20% vs. 1/75; 1%, P < 0.001) compared with S. pneumoniae. CONCLUSIONS We report increasing rates of pediatric empyema with higher proportions requiring ICU treatment. The most common pathogens detected were S. pneumoniae, S. aureus and S. pyogenes. Despite high 13-valent pneumococcal conjugate vaccine coverage, serotype 3 was the most common S. pneumoniae serotype identified.
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Affiliation(s)
- Stuart Haggie
- From the Department of Respiratory Medicine, the Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Dominic A Fitzgerald
- From the Department of Respiratory Medicine, the Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Chetan Pandit
- From the Department of Respiratory Medicine, the Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Hiran Selvadurai
- From the Department of Respiratory Medicine, the Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Paul Robinson
- From the Department of Respiratory Medicine, the Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Hasantha Gunasekera
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Philip Britton
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Infectious Diseases, the Children's Hospital at Westmead, Sydney, New South Wales, Australia
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Management of paediatric empyema by video-assisted thoracoscopic surgery (VATS) versus chest drain with fibrinolysis: Systematic review and meta-analysis. Paediatr Respir Rev 2019; 30:42-48. [PMID: 31130425 DOI: 10.1016/j.prrv.2018.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 09/05/2018] [Indexed: 01/08/2023]
Abstract
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.
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Bataev SM, Zurbaev NT, Molotov RS, Ignatiev RO, Afaunov MV, Fedorov AK, Bataev AS. The first experience of the use of hydro-surgical technologies in the treatment of children with pulmatic-pleural complications of destructive pneumonia. Khirurgiia (Mosk) 2019:15-23. [PMID: 31355809 DOI: 10.17116/hirurgia201907115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
UNLABELLED Drainage and endoscopic methods of sanitation of the pleural cavity do not always allow to achieve effective debridement of pathological contents. AIM To development and introduction into clinical practice of hydrosurgical technologies for debridement of the pleural cavity. MATERIAL AND METHODS From 423 children with acute community-acquired pneumonia 88 (20.80%) children destructive pneumonia were diagnosed. Of the 88 patients with destructive pneumonia, 28 patients did not have pleural complications and were excluded from the study. 60 patients were divided into 2 groups depending on the method of surgical treatment. In the first group (n=30), two additional subgroups were formed: IA group (main n=15) - they carried out drainage and washing the pleural cavity with saline; IB group (control n=15) - only drainage of the pleural cavity. The second group (n=30) were also divided into 2 subgroups; Group IIA (main n=15) children operated according to the method of video-assisted thoracoscopic sanitations of the pleural cavity developed by us using hydrosurgical technologies; Group IIB (control n=15) - children are operated on by the method of traditional video-assisted thoracoscopic sanitations of the pleural cavity. A prospective, non-randomized, single-center study was conducted to evaluate the effectiveness of various treatments. The treatment plan was determined on the basis of a combination of anamnesis, clinical and instrumental studies and laboratory parameters. RESULTS All studied in the comparison groups were homogeneous by sex, weight and height. The results of applying the Kruskal-Wallis test revealed statistically significant differences between the groups for the periods of relief of the intoxication syndrome (p<0.001) and the periods of relief of the pain syndrome (p=0.012) in favor of the main group. Summarizing all analyzing the parameters in the comparison groups allowed us to prove the advantage of the proposed treatment methods over the treatment methods used in the control groups. CONCLUSION Hydrosurgical methods of treatment demonstrate obvious clinical and economic efficacy, which leads to the rapid reexpantion of the affected lung.
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Affiliation(s)
- S M Bataev
- Pirogov Russian National Research Medical University, Moscow, Russia
- SperanskiyChildren's Municipal Hospital #9, Moscow, Russia
| | - N T Zurbaev
- Pirogov Russian National Research Medical University, Moscow, Russia
- SperanskiyChildren's Municipal Hospital #9, Moscow, Russia
| | - R S Molotov
- Pirogov Russian National Research Medical University, Moscow, Russia
- SperanskiyChildren's Municipal Hospital #9, Moscow, Russia
| | - R O Ignatiev
- Pirogov Russian National Research Medical University, Moscow, Russia
- SperanskiyChildren's Municipal Hospital #9, Moscow, Russia
| | - M V Afaunov
- Pirogov Russian National Research Medical University, Moscow, Russia
- SperanskiyChildren's Municipal Hospital #9, Moscow, Russia
| | - A K Fedorov
- Pirogov Russian National Research Medical University, Moscow, Russia
- SperanskiyChildren's Municipal Hospital #9, Moscow, Russia
| | - A S Bataev
- Pirogov Russian National Research Medical University, Moscow, Russia
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Knebel R, Fraga JC, Amantea SL, Isolan PBS. Videothoracoscopic surgery before and after chest tube drainage for children with complicated parapneumonic effusion. J Pediatr (Rio J) 2018; 94:140-145. [PMID: 28837796 DOI: 10.1016/j.jped.2017.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 02/11/2017] [Accepted: 03/06/2017] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To evaluate the effectiveness of videothoracoscopic surgery in the treatment of complicated parapneumonic pleural effusion and to determine whether there is a difference in the videothoracoscopic surgery outcome before or after the chest tube drainage. METHODS The medical records of 79 children (mean age 35 months) undergoing videothoracoscopic surgery from January 2000 to December 2011 were retrospectively reviewed. The same treatment algorithm was used in the management of all patients. Patients were divided into two groups: in group 1, videothoracoscopic surgery was performed as the initial procedure; in group 2, videothoracoscopic surgery was performed after previous chest tube drainage. RESULTS Videothoracoscopic surgery was effective in 73 children (92.4%); the other six (7.6%) needed another procedure. Sixty patients (75.9%) were submitted directly to videothoracoscopic surgery (group 1) and 19 (24%) primarily underwent chest tube drainage (group 2). Primary videothoracoscopic surgery was associated with a decrease of hospital stay (p=0.05), time to resolution (p=0.024), and time with a chest tube (p<0.001). However, there was no difference between the groups regarding the time until fever resolution, time with a chest tube, and the hospital stay after videothoracoscopic surgery. No differences were observed between groups regarding the need for further surgery and the presence of complications. CONCLUSIONS Videothoracoscopic surgery is a highly effective procedure for treating children with complicated parapneumonic pleural effusion. When videothoracoscopic surgery is indicated in the presence of loculations (stage II or fibrinopurulent), no difference were observed in time of clinical improvement and hospital stay among the patients with or without chest tube drainage before videothoracoscopic surgery.
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Affiliation(s)
- Rogerio Knebel
- Universidade Federal de Santa Maria (UFSM), Hospital Universitário de Santa Maria (HUSM), Santa Maria, RS, Brazil.
| | - Jose Carlos Fraga
- Universidade Federal do Rio Grande do Sul (UFRGS), Faculdade de Medicina, Departamento de Cirurgia, Porto Alegre, RS, Brazil; Universidade Federal do Rio Grande do Sul (UFRGS), Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil
| | - Sergio Luis Amantea
- Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil; Hospital Santo Antônio de Porto Alegre, Porto Alegre, RS, Brazil
| | - Paola Brolin Santis Isolan
- Universidade Federal do Rio Grande do Sul (UFRGS), Faculdade de Medicina, Departamento de Cirurgia, Porto Alegre, RS, Brazil; Universidade Federal do Rio Grande do Sul (UFRGS), Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil
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Knebel R, Fraga JC, Amantéa SL, Isolan PBS. Videothoracoscopic surgery before and after chest tube drainage for children with complicated parapneumonic effusion. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2018. [DOI: 10.1016/j.jpedp.2017.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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17
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Lewis MR, Micic TA, Doull IJM, Evans A. Real-time ultrasound-guided pigtail catheter chest drain for complicated parapneumonic effusion and empyema in children - 16-year, single-centre experience of radiologically placed drains. Pediatr Radiol 2018; 48:1410-1416. [PMID: 29951836 PMCID: PMC6105150 DOI: 10.1007/s00247-018-4171-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 03/29/2018] [Accepted: 04/12/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chest tube drainage with fibrinolytics is a cost-effective treatment option for parapneumonic effusion and empyema in children. Although the additional use of ultrasound (US) guidance is recommended, this is rarely performed in real time to direct drain insertion. OBJECTIVE To evaluate the effectiveness and safety of real-time US-guided, radiologically placed chest drains at a tertiary university hospital. MATERIALS AND METHODS This was a retrospective review over a 16-year period of all children with parapneumonic effusion or empyema undergoing percutaneous US-guided drainage at our centre. RESULTS Three hundred and three drains were placed in 285 patients. Treatment was successful in 93% of patients after a single drain (98.2% success with 2 or 3 drains). Five children had peri-insertion complications, but none was significant. The success rate improved with experience. Although five patients required surgical intervention, all children treated since 2012 were successfully treated with single-tube drainage only and none has required surgery. CONCLUSION Our technique for inserting small-bore (≤8.5 F) catheter drains under US guidance is effective and appears to be a safe procedure for first-line management of complicated parapneumonic effusion and empyema.
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Affiliation(s)
- Megan R. Lewis
- Department of Postgraduate Medical and Dental Education at Cardiff University, Heath Park Way, Cardiff, UK CF14 4YU
| | - Thomas A. Micic
- Department of Paediatric Radiology, Children’s Hospital for Wales, Heath Park, Cardiff, UK CF14 4XW
| | - Iolo J. M. Doull
- Department of Paediatric Respiratory Medicine, Children’s Hospital for Wales, Cardiff, UK CF14 4XW
| | - Alison Evans
- Department of Paediatric Radiology, Children’s Hospital for Wales, Heath Park, Cardiff, UK CF14 4XW
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18
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Quick RD, Auth MJ, Fernandez M, Meyer T, Merkel KG, Thoreson LM, Hauger SB. Decreasing Exposure to Radiation, Surgical Risk, and Costs for Pediatric Complicated Pneumonia: A Guideline Evaluation. Hosp Pediatr 2017; 7:287-293. [PMID: 28450309 DOI: 10.1542/hpeds.2016-0077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES This report describes the creation and successful implementation of a complicated pneumonia care algorithm at our institution. Outcomes are measured for specific goals of the algorithm: to decrease radiation exposure, surgical risk, and patient charges without adversely affecting clinical outcomes. METHODS We describe steps involved in algorithm creation and implementation at our institution. To depict outcomes of the algorithm, we completed a retrospective cohort study of hospitalized pediatric patients with a diagnosis of complicated pneumonia at a single institution between January 2010 and April 2016 who met criteria for the algorithm. Charts were manually reviewed and data were analyzed via Wilcoxon rank sum, χ2, and Fisher's exact tests. RESULTS Throughout the algorithm creation process, our institution began to see a change in practice. We saw a statistically significant decrease in the number of patients who underwent a chest computed tomography scan and an increase in patients who underwent a chest ultrasound (P < .001). We also saw an increase in the use of chest tube placement with fibrinolytics and a decrease in the use of video-assisted thoracoscopic surgery as the initial chest procedure (P ≤ .001) after algorithm implementation. These interventions reduced related charges without significantly affecting length of stay, readmission rate, or other variables studied. CONCLUSIONS The collaborative creation and introduction of an algorithm for the management of complicated pneumonia at our institution, combined with an effort among physicians to incorporate evidence-based clinical care into practice, led to reduced radiation exposure, surgical risk, and cost to patient.
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Segerer FJ, Seeger K, Maier A, Hagemann C, Schoen C, van der Linden M, Streng A, Rose MA, Liese JG. Therapy of 645 children with parapneumonic effusion and empyema-A German nationwide surveillance study. Pediatr Pulmonol 2017; 52:540-547. [PMID: 27648553 PMCID: PMC5396379 DOI: 10.1002/ppul.23562] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 08/06/2016] [Accepted: 08/10/2016] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To evaluate the initial management of pediatric parapneumonic effusion or pleural empyema (PPE/PE) with regard to length of hospital stay (LOS). METHODS Collection of pediatric PPE/PE cases using a nationwide surveillance system (ESPED) from 10/2010 to 06/2013, in all German pediatric hospitals. Inclusion of PPE/PE patients <18 years of age requiring drainage or with a PPE/PE persistence >7 days. Staging of PPE/PE based on reported pleural sonographic imaging. Comparison of LOS after diagnosis between children treated with different forms of initial invasive procedures performed ≤3 days after PPE/PE diagnosis: pleural puncture, draining catheter, intrapleural fibrinolytic therapy, surgical procedures. RESULTS Inclusion of 645 children (median age 5 years); median total LOS 17 days. Initial therapy was non-invasive in 282 (45%) cases and invasive in 347 (55%) cases (pleural puncture: 62 [10%], draining catheter: 153 [24%], intrapleural fibrinolytic therapy: 89 [14%], surgical procedures: 43 [7%]). LOS after diagnosis did not differ between children initially treated with different invasive procedures. Results remained unchanged when controlling for sonographic stage, preexisting diseases, and other potential confounders. Repeated use of invasive procedures was observed more often after initial non-invasive treatment or pleural puncture alone than after initial pleural drainage, intrapleural fibrinolytic therapy or surgery. CONCLUSIONS Initial treatment with intrapleural fibrinolytic therapy or surgical procedures did not result in shorter LOS than initial pleural puncture alone. Larger prospective studies are required to investigate which children benefit significantly from more intensive forms of initial invasive treatment. Pediatr Pulmonol. 2017;52:540-547. © 2016 The Authors. Pediatric Pulmonology Published by Wiley Periodicals, Inc.
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Affiliation(s)
| | - Karin Seeger
- Department of Pediatrics, University of Würzburg, Würzburg, Germany
| | - Anna Maier
- Department of Pediatrics, University of Würzburg, Würzburg, Germany
| | | | - Christoph Schoen
- Institute of Hygiene and Microbiology, University of Würzburg, Würzburg, Germany
| | - Mark van der Linden
- Department of Medical Microbiology, National Reference Center for Streptococci, University Hospital RWTH Aachen, Aachen, Germany
| | - Andrea Streng
- Department of Pediatrics, University of Würzburg, Würzburg, Germany
| | - Markus A Rose
- Children's Hospital, Goethe University of Frankfurt, Frankfurt, Germany
| | - Johannes G Liese
- Department of Pediatrics, University of Würzburg, Würzburg, Germany
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Abstract
BACKGROUND Empyema refers to pus in the pleural space, commonly due to adjacent pneumonia, chest wall injury, or a complication of thoracic surgery. A range of therapeutic options are available for its management, ranging from percutaneous aspiration and intercostal drainage to video-assisted thoracoscopic surgery (VATS) or thoracotomy drainage. Intrapleural fibrinolytics may also be administered following intercostal drain insertion to facilitate pleural drainage. There is currently a lack of consensus regarding optimal treatment. OBJECTIVES To assess the effectiveness and safety of surgical versus non-surgical treatments for complicated parapneumonic effusion or pleural empyema. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2016, Issue 9), MEDLINE (Ebscohost) (1946 to July week 3 2013, July 2015 to October 2016) and MEDLINE (Ovid) (1 May 2013 to July week 1 2015), Embase (2010 to October 2016), CINAHL (1981 to October 2016) and LILACS (1982 to October 2016) on 20 October 2016. We searched ClinicalTrials.gov and WHO International Clinical Trials Registry Platform for ongoing studies (December 2016). SELECTION CRITERIA Randomised controlled trials that compared a surgical with a non-surgical method of management for all age groups with pleural empyema. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked the data for accuracy. We contacted trial authors for additional information. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS We included eight randomised controlled trials with a total of 391 participants. Six trials focused on children and two on adults. Trials compared tube thoracostomy drainage (non-surgical), with or without intrapleural fibrinolytics, to either VATS or thoracotomy (surgical) for the management of pleural empyema. Assessment of risk of bias for the included studies was generally unclear for selection and blinding but low for attrition and reporting bias. Data analyses compared thoracotomy versus tube thoracostomy and VATS versus tube thoracostomy. We pooled data for meta-analysis where appropriate. We performed a subgroup analysis for children along with a sensitivity analysis for studies that used fibrinolysis in non-surgical treatment arms.The comparison of open thoracotomy versus thoracostomy drainage included only one study in children, which reported no deaths in either treatment arm. However, the trial showed a statistically significant reduction in mean hospital stay of 5.90 days for those treated with primary thoracotomy. It also showed a statistically significant reduction in procedural complications for those treated with thoracotomy compared to thoracostomy drainage. We downgraded the quality of the evidence for length of hospital stay and procedural complications outcomes to moderate due to the small sample size.The comparison of VATS versus thoracostomy drainage included seven studies, which we pooled in a meta-analysis. There was no statistically significant difference in mortality or procedural complications between groups. This was true for both adults and children with or without fibrinolysis. However, mortality data were limited: one study reported one death in each treatment arm, and seven studies reported no deaths. There was a statistically significant reduction in mean length of hospital stay for those treated with VATS. The subgroup analysis showed the same result in adults, but there was insufficient evidence to estimate an effect for children. We could not perform a separate analysis for fibrinolysis for this outcome because all included studies used fibrinolysis in the non-surgical arms. We downgraded the quality of the evidence to low for mortality (due to wide confidence intervals and indirectness), and moderate for other outcomes in this comparison due to either high heterogeneity or wide confidence intervals. AUTHORS' CONCLUSIONS Our findings suggest there is no statistically significant difference in mortality between primary surgical and non-surgical management of pleural empyema for all age groups. Video-assisted thoracoscopic surgery may reduce length of hospital stay compared to thoracostomy drainage alone.There was insufficient evidence to assess the impact of fibrinolytic therapy.A number of common outcomes were reported in the included studies that were not directly examined in our primary and secondary outcomes. These included duration of chest tube drainage, duration of fever, analgesia requirement, and total cost of treatment. Future studies focusing on patient-centred outcomes, such as patient functional scores, and other clinically relevant outcomes, such as radiographic improvement, treatment failure rates, and amount of fluid drainage, are needed to inform clinical decisions.
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Affiliation(s)
| | - Tze Yang Chin
- The Prince Charles HospitalRode RoadChermsideQueenslandAustralia4032
- The University of QueenslandSchool of Medicine288 Herston RoadBrisbaneQLDAustralia4006
| | - Mieke L van Driel
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineBrisbaneQueenslandAustralia4029
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Livingston MH, Colozza S, Vogt KN, Merritt N, Bütter A. Making the transition from video-assisted thoracoscopic surgery to chest tube with fibrinolytics for empyema in children: Any change in outcomes? Can J Surg 2017; 59:167-71. [PMID: 26999475 DOI: 10.1503/cjs.014714] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND There is ongoing variation in the use of video-assisted thoracoscopic surgery (VATS) and chest tube with fibrinolytics (CTWF) for empyema in children. Our objective was to report outcomes from a centre that recently made the transition from VATS to CTWF as the primary treatment modality. METHODS We conducted a historical cohort study of children with empyema treated with either primary VATS (between 2005 and 2009) or CTWF (between 2009 and 2013). RESULTS Sixty-seven children underwent pleural drainage for empyema during the study period: 28 (42%) were treated with primary VATS, and 39 (58%) underwent CTWF. There were no significant differences between the VATS and CTWF groups for length of stay (8 v. 9 d, p = 0.61) or need for additional procedures (4% v. 13%, p = 0.19). Length of stay varied widely for both VATS (4-53 d) and CTWF (5-46 d). Primary VATS failed in 1 (4%) patient, who required an additional chest tube, and CTWF failed in 5 (13%) patients. Additional procedures included 3 rescue VATS, 2 additional chest tubes and 1 thoracotomy. All patients recovered and were discharged home. CONCLUSION Primary VATS and CTWF were associated with similar outcomes in children with empyema. There appears to be a subset of children at risk for treatment failure with CTWF. Further research is needed to determine if these patients would benefit from primary VATS.
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Affiliation(s)
- Michael H Livingston
- From the Division of General Surgery, Western University (Livingston, Vogt, Merritt, Bütter); the Schulich School of Medicine & Dentistry, Western University (Colozza); and the Division of Pediatric Surgery, Western University (Merritt, Bütter), London, Ont
| | - Sara Colozza
- From the Division of General Surgery, Western University (Livingston, Vogt, Merritt, Bütter); the Schulich School of Medicine & Dentistry, Western University (Colozza); and the Division of Pediatric Surgery, Western University (Merritt, Bütter), London, Ont
| | - Kelly N Vogt
- From the Division of General Surgery, Western University (Livingston, Vogt, Merritt, Bütter); the Schulich School of Medicine & Dentistry, Western University (Colozza); and the Division of Pediatric Surgery, Western University (Merritt, Bütter), London, Ont
| | - Neil Merritt
- From the Division of General Surgery, Western University (Livingston, Vogt, Merritt, Bütter); the Schulich School of Medicine & Dentistry, Western University (Colozza); and the Division of Pediatric Surgery, Western University (Merritt, Bütter), London, Ont
| | - Andreana Bütter
- From the Division of General Surgery, Western University (Livingston, Vogt, Merritt, Bütter); the Schulich School of Medicine & Dentistry, Western University (Colozza); and the Division of Pediatric Surgery, Western University (Merritt, Bütter), London, Ont
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Erlichman I, Breuer O, Shoseyov D, Cohen-Cymberknoh M, Koplewitz B, Averbuch D, Erlichman M, Picard E, Kerem E. Complicated community acquired pneumonia in childhood: Different types, clinical course, and outcome. Pediatr Pulmonol 2017; 52:247-254. [PMID: 27392317 DOI: 10.1002/ppul.23523] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 05/06/2016] [Accepted: 06/29/2016] [Indexed: 11/09/2022]
Abstract
UNLABELLED The incidence of pediatric community acquired complicated pneumonia (PCACP) is increasing. Questions addressed: Are different types of PCACP one disease? How do different treatment protocols affect the outcome? METHODS Retrospective analysis of medical records of PCACP hospitalizations in the three major hospitals in Jerusalem in the years 2001-2010 for demographics, clinical presentation, management, and outcome. RESULTS Of the 144 children (51% aged 1-4 years), 91% of Jewish origin; 40% had para-pneumonic effusion (PPE), 40% empyema (EMP), and 20% necrotizing pneumonia (NP). Bacterial origin was identified in 42% (empyema 79%, P = 0.009), most common S. pneumoniae (32%), group A streptococcus (9%). Patients with EMP, compared to PPE and NP, were less likely to receive prior antibiotic treatment (35% vs. 57% and 59%, respectively, P = 0.04). Mean hospitalization was longer in patients with NP followed by EMP and PPE (16.4 ± 10.6, 15.2 ± 7.9, and 12.7 ± 4.7 days, respectively), use of fibrinolysis was not associated with the outcome. All children had recovered to discharge regardless of antibiotic therapy or fibrinolysis. ANSWER NP is a more severe disease with prolonged morbidity and hospitalization in spite of prior antibiotic treatment. All types had favorable outcome regardless of treatment-protocol. Complicated pneumonia has an ethnic predominance. Pediatr Pulmonol. 2017;52:247-254. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Ira Erlichman
- Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Oded Breuer
- Pediatric Pulmonology Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - David Shoseyov
- Pediatric Pulmonology Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | - Benjamin Koplewitz
- Pediatric Radiology Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Diana Averbuch
- Pediatric Infectious Disease Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Matti Erlichman
- Department of Pediatric Emergency Medicine, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Elie Picard
- Pediatric Pulmonology Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Eitan Kerem
- Pediatric Pulmonology Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Empyema in Children: Update of Aetiology, Diagnosis and Management Approaches. CURRENT PULMONOLOGY REPORTS 2017. [DOI: 10.1007/s13665-017-0161-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Richards MK, Mcateer JP, Edwards TC, Hoffman LR, Kronman MP, Shaw DW, Goldin AB. Establishing Equipoise: National Survey of the Treatment of Pediatric Para-Pneumonic Effusion and Empyema. Surg Infect (Larchmt) 2016; 18:137-142. [PMID: 27898253 DOI: 10.1089/sur.2016.134] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Despite six randomized trials of various treatments for pediatric para-pneumonic effusion (PPE), management approaches differ. The purpose of this study was to gain insight into opinions on PPE treatment with the goal of designing a definitive trial to generate consensus intervention guidelines. METHODS To evaluate physician opinions regarding PPE management, we developed a survey based on input from a nationwide, multi-disciplinary advisory group that established content validity. The survey was disseminated broadly to six pediatric medicine and interventional radiology groups. Descriptive and χ2 statistics were calculated. RESULTS There were 741 respondents (response rate 13.1%), of whom 52.2% were surgeons, 15.2% hospitalists, 14.2% pulmonologists, 12.4% intensivists, and 6.0% interventional radiologists. Nearly all respondents (97.3%) reported caring primarily for pediatric patients. Eighty percent reported no written institutional treatment guidelines. Nearly all (90.3%) agreed that patients require antibiotics, but there was disagreement regarding their duration. Respondents also were split as to how often PPE required drainage. There were multiple absolute indications for drainage, including mediastinal shift on chest radiograph (67.2%) and loculations on imaging (47.7%). There were substantial differences in the preferred first-line methods of drainage based on the treating physician's specialty, with surgeons preferring tube thoracostomy and a fibrinolytic agent (42.0%) or video-assisted thoracoscopic surgery (41.6%), whereas interventional radiologists preferred either a tube thoracostomy (46.4%) or a tube thoracostomy with a fibrinolytic agent (39.3%) (p < 0.001). A large majority (75.3%) believed that the published evidence does not identify the optimal intervention. CONCLUSIONS There is a lack of consensus regarding the optimal treatment of PPE. Respondents believed the published evidence is inconclusive and were willing to participate in a prospective trial. These findings will help inform the design of a randomized, pragmatic clinical trial to optimize PPE management.
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Affiliation(s)
- Morgan K Richards
- 1 Department of Surgery, University of Washington , Seattle, Washington
| | - Jarod P Mcateer
- 1 Department of Surgery, University of Washington , Seattle, Washington
| | - Todd C Edwards
- 2 Department of Health Services, University of Washington , Seattle, Washington
| | - Lucas R Hoffman
- 3 Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital , Seattle
| | - Matthew P Kronman
- 4 Department of Pediatrics, Division of Infectious Disease, Seattle Children's Hospital , Seattle
| | - Dennis W Shaw
- 5 Department of Radiology, Seattle Children's Hospital
| | - Adam B Goldin
- 6 Department of Thoracic and General Surgery, Seattle Children's Hospital
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Bender MT, Ward AN, Iocono JA, Saha SP. Current Surgical Management of Empyema Thoracis in Children: A Single-center Experience. Am Surg 2015. [DOI: 10.1177/000313481508100915] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Empyema is a morbid complication of pneumonia in children, whose gold standard of surgical treatment technique remains undefined. Historically, treatment consisted of open thoracotomy with decortication. We evaluate the effectiveness and safety of video-assisted thoracoscopic surgery (VATS) as a surgical treatment in for empyema thoracis in a pediatric population at a single institution from 2005 to 2013. After receiving Institutional Review Board approval, we performed a retrospective chart review of children surgically treated for empyema as a complication of pneumonia from 2005 to 2013. Charts were reviewed for the type of procedure performed (VATS or open thoracotomy), comorbid conditions, preoperative status, operative outcomes, and postoperative status. A total of 112 pediatric patients were treated surgically for empyema. Surgical treatment consisted of VATS in all cases; no open thoracotomy procedures were performed. The success rate of VATS in our study was 96.4 per cent. Mean total length of stay was found to be 8.8 days, whereas postoperative length of stay was 6.3 days. Mean postoperative chest tube duration was 3.4 days. Perioperative complication rate was 11.6 per cent, with respiratory failure being the most common complication. The data from our study demonstrate that the exclusive use of VATS in children for the surgical management of all stages of empyema was safe and produced results with high efficacy. We consider VATS to be the new gold standard for surgical drainage of empyema.
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Affiliation(s)
| | - Austin N. Ward
- Graduate Medical Education, General Surgery Residency Program
| | | | - Sibu P. Saha
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky, Lexington, Kentucky
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Shirota C, Uchida H. Initial treatment of septated parapneumonic empyema with drainage plus fibrinolytic agents is equally effective as video-assisted thoracoscopic surgery, and is suitable as first-line therapy. Transl Pediatr 2015; 4:41-4. [PMID: 26835359 PMCID: PMC4729070 DOI: 10.3978/j.issn.2224-4336.2015.02.01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
It is thought that 0.6-2% of cases of pneumonia in children are complicated by parapneumonic empyema. The mainstay treatment options for empyema are pleural chest drainage plus fibrinolysis or video-assisted thoracoscopic surgery (VATS). Marhuenda et al. reported the results of a prospective, multicenter, clinical trial in which patients with parapneumonic empyema were randomized to either drainage plus urokinase or to VATS. That showed that the median postoperative stay, median hospital stay, and number of febrile days after treatment were not significantly different between the VATS group and the urokinase group. Only three other prospective randomized trials have been conducted with the same objective. The results in these studies had partially different among four trials. But all studies described that it is apparent that VATS is not more effective than fibrinolytic treatment. Intrapleural fibrinolytic treatment, which is much less invasive and lower inexpensive than VATS, is an effective and safe alternative to surgical treatment of complicated empyema. VATS would be reserved for patients who fail to respond to chemical/enzymatic debridement. We need additional randomized controlled trials with relevant inclusion/exclusion criteria and adequate sample sizes to determine the optimal therapy for parapneumonic-complicated empyema in children.
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Affiliation(s)
- Chiyoe Shirota
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Showa, Nagoya 466-8550, Japan
| | - Hiroo Uchida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Showa, Nagoya 466-8550, Japan
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Marhuenda C, Barceló C, Fuentes I, Guillén G, Cano I, López M, Hernández F, Pérez-Yarza EG, Matute JA, García-Casillas MA, Alvarez V, Moreno-Galdó A. Urokinase versus VATS for treatment of empyema: a randomized multicenter clinical trial. Pediatrics 2014; 134:e1301-7. [PMID: 25349313 DOI: 10.1542/peds.2013-3935] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | - Indalecio Cano
- Department of Pediatric Surgery, Hospital 12 de Octubre, Madrid, Spain
| | - María López
- Department of Pediatric Surgery, Hospital 12 de Octubre, Madrid, Spain
| | | | - Eduardo G Pérez-Yarza
- Department of Pediatrics, University of the Basque Country, UPV/EHU, San Sebastian, Spain; Division of Pediatric Respiratory Medicine, Hospital Universitario Donostia-Instituto Biodonostia, San Sebastián, España; Biomedical Research Centre Network for Respiratory Diseases (CIBERES), San Sebastián, Spain
| | - José A Matute
- Department of Pediatric Surgery, Hospital Gregorio Marañón, Madrid, Spain; and
| | | | - Víctor Alvarez
- Department of Pediatric Surgery, Hospital Central de Asturias, Oviedo, Spain
| | - Antonio Moreno-Galdó
- Pediatric Pulmonology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona. Barcelona, Spain
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