1
|
Menon P. Debate 2: Is the Management of Childhood Empyema Primarily Medical, or Surgical? Indian J Pediatr 2023; 90:915-919. [PMID: 37184715 DOI: 10.1007/s12098-023-04589-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 03/17/2023] [Indexed: 05/16/2023]
Abstract
The management of empyema thoracis has changed in the past 1-2 decades with the advent of video-assisted thoracoscopy (VATS), the surgeon's weapon and fibrinolytic agents, the physician's weapon. Inappropriate use of either and inability to accept their failure in some cases cause prolonged morbidity in an unsuspecting patient. VATS has been shown to be very effective in stage 2 empyema and is associated with early amelioration of symptoms and early discharge from hospital. Open thoracotomy still plays an important role in the management of delayed and complicated cases of empyema and has always produced good results. Some complications seen by surgeons are related to previous interventions and delayed referral. Lung status plays an important role in post operative recovery. In patients requiring intervention, both medical and surgical options should be considered without bias early in the management and discussed with care-givers to give best outcome.
Collapse
Affiliation(s)
- Prema Menon
- Department of Pediatric Surgery, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (P.G.I.M.E.R.), Chandigarh, 160012, India.
| |
Collapse
|
2
|
Gupta R, Mathur P, Bhandari A. Muscle-Sparing Skin Crease Incision Posterolateral Thoracotomies in Pediatric Patients: Our Experience. J Indian Assoc Pediatr Surg 2022; 27:309-316. [PMID: 35733591 PMCID: PMC9208698 DOI: 10.4103/jiaps.jiaps_43_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/04/2021] [Accepted: 10/29/2021] [Indexed: 11/18/2022] Open
Abstract
Context Standard posterolateral muscle cutting thoracotomies in pediatric patients are associated with morbidities in terms of poor motor and esthetic outcomes and also more postoperative analgesia requirement, when compared with muscle-sparing technique. Aims The aim of this study is to evaluate the outcomes of muscle-sparing skin crease incision posterolateral thoracotomies in pediatric patients in terms of abovementioned variables. Settings and Design This prospective observational study was conducted over a period from January 2016 to July 2020 in a tertiary care teaching institute. Materials and Methods All patients of stage 3 empyema and pulmonary hydatidosis were included in the study. Results Thirty-nine patients fulfilled the inclusion criteria. There were 38 children with organized (Stage 3) empyema and one patient with bilateral lung hydatid. There were 24 males and 15 females; age ranging from 6 months to 15 years. Right thoracotomy was performed in 28, left in 10, and bilateral in one patient with lung hydatid. Adequate exposure was achieved in all cases. Decortication with complete excision of thickened parietal pleura with stripping of the visceral peel and release of the entrapped lung was performed in all 38 patients. In 5 children along with decortication, repair of bronchopleural fistula due to necrotizing pneumonia was performed. Bilateral thoracotomies with pericystectomies were performed with a gap of 3 weeks for lung hydatid. Lung expansion assessment at 3 months was satisfactory. Ultrasound assessment of the latissimus dorsi muscle and serratus anterior muscle at 4 weeks revealed complete integrity in all the cases. Most of the patients achieved satisfactory motor and esthetic outcomes. Conclusions Muscle-sparing skin crease incision posterolateral thoracotomy is a viable alternative to standard posterolateral muscle cutting thoracotomy, especially in a resource-challenged setting. The technique is easy to perform with satisfactory exposure.
Collapse
Affiliation(s)
- Rahul Gupta
- Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India,Address for correspondence: Dr. Rahul Gupta, Associate Professor, Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India. E-mail:
| | - Praveen Mathur
- Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India
| | - Anu Bhandari
- Department of Radiodiagnosis, SMS Medical College, Jaipur, Rajasthan, India
| |
Collapse
|
3
|
Jaiswal LS, Pandit N, Sah B, Prasad JN. Open pleural decortication for the late stage empyema thoracis in children: a retrospective observational study from a tertiary hospital of eastern Nepal. Trop Doct 2020; 50:203-209. [PMID: 32345149 DOI: 10.1177/0049475520921279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The management of late-stage empyema thoracis requires surgical intervention. We performed a retrospective descriptive analysis of open pleural decortication for late stage empyema thoracis in 55 children (age ≤ 15 years; median age = 6 years; age range = 1-15 years; 40 [72.7%] boys) over 42 months. The median time to thoracotomy from the onset of symptoms was 24 days, and the median duration of hospital stay before and after surgery was 15 and 4 days, respectively. Three (5.5%) patients had necrotising pneumonia, requiring debridement; 4 (7.3%) patients had superficial surgical site infection; 12 (21.8%) patients had perioperative pus culture positive for bacteria; and 3 (5.5%) patients had tubercular aetiology. There was no operative mortality. At median follow-up of 18 months, all patients are in good general health. Open pleural decortication leads to rapid resolution of symptoms and reduces hospital stay in paediatric late-stage empyema thoracis.
Collapse
Affiliation(s)
- Lokesh S Jaiswal
- Associate Professor, Department of Surgery, B P Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal
| | - Narendra Pandit
- Associate Professor, Department of Surgery, B P Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal
| | - Bijay Sah
- Assistant Professor Department of Surgery B P Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal
| | - Jagat N Prasad
- Associate Professor, Department of Surgery, B P Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal
| |
Collapse
|
4
|
Santanakrishnan R, Murali GS, Javaregowda D, Shankar G, Babu N, Jadhav V. Thoracoscopy in stage 3 empyema thoracis in children - A safe and feasible alternative to thoracotomy. J Pediatr Surg 2020; 55:756-760. [PMID: 31493886 DOI: 10.1016/j.jpedsurg.2019.08.007] [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: 02/10/2019] [Revised: 06/08/2019] [Accepted: 08/07/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Even though the role of thoracoscopy is well defined in Stage 2 empyema thoracis and is very popular, its role in the management of advanced empyema is still unclear. The technical difficulties and the potential complications are the principal reasons for the hesitancy in attempting video assisted thoracoscopic surgery (VATS) in advanced stages. METHODS We prospectively studied the safety, feasibility and effectiveness of VATS for decortication in Stage 3 empyema. RESULTS In the 61 cases that we attempted VATS over the last 7 years, we could complete the procedure in 45 patients (73.77%). Four children among them required re-do procedure later for persistent problems. Conversion to thoracotomy was needed in 16 patients (26.23%). The post-operative hospital stay of patients who underwent primary VATS decortication was significantly less when compared to patients requiring conversion (p < 0.0001). CONCLUSION Thoracoscopy is a safe, feasible and effective option even in advanced empyema thoracis and should be offered in centers with adequate expertise and set up. LEVEL OF EVIDENCE Level II.
Collapse
Affiliation(s)
- Ramesh Santanakrishnan
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, South Hospital Complex, Dharmaram College Post, Bangalore - 560029, Karnataka, India
| | - Govindappa Saroja Murali
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, South Hospital Complex, Dharmaram College Post, Bangalore - 560029, Karnataka, India.
| | - Deepak Javaregowda
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, South Hospital Complex, Dharmaram College Post, Bangalore - 560029, Karnataka, India
| | - Gowri Shankar
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, South Hospital Complex, Dharmaram College Post, Bangalore - 560029, Karnataka, India
| | - Narendra Babu
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, South Hospital Complex, Dharmaram College Post, Bangalore - 560029, Karnataka, India
| | - Vinay Jadhav
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, South Hospital Complex, Dharmaram College Post, Bangalore - 560029, Karnataka, India
| |
Collapse
|
5
|
Abstract
Aim and Objective This study aims to report 100 pediatric patients of empyema thoracis treated by open decortication, highlighting the presentation, delay in referral, operative findings, the response to surgical intervention, and follow-up. Materials and Methods All the children who underwent open decortication for stage III empyema thoracis during the study period January 2015-December 2016 were included. Preoperative workup included hemogram, serum protein, chest radiographs, and contrast-enhanced computed tomographic (CECT) scan of the chest. Results One hundred (65 males, 35 females) (age 2 months-13 years, mean 4.5 years) were operated during a 2-year period. Among them, 90% patients were referred 3 weeks after the onset of disease. Intercostal chest drainage (ICD) had been inserted in (95) 95% cases. Thickened pleura, multiloculated pus, and lung involvement were invariably seen on CECT scan. Bronchopleural fistula was present in five patients. Decortication and removal of necrotic tissue were performed in all the patients. Mean duration of postoperative ICD was 4 days. Follow-up ranged from 1 month to 2 years (mean 12 months). There was no mortality. Five patients had proven tuberculosis. Only 10% presented within the early period of the disease. Conclusion The duration of the disease had a direct relationship with the thickness of the pleura and injury to the underlying lung. Delayed referral causes irreversible changes in the lung prolonging recovery. Meticulous open surgical debridement gives gratifying results. The status of the lung at the end of surgery is a major prognostic factor.
Collapse
Affiliation(s)
- Aditya Pratap Singh
- Department of Pediatric Surgery, SMS Medical College Jaipur, Rajasthan, India
| | - Arvind Kumar Shukla
- Department of Pediatric Surgery, SMS Medical College Jaipur, Rajasthan, India
| | - Pramila Sharma
- Department of Pediatric Surgery, SMS Medical College Jaipur, Rajasthan, India
| | - Jyotsna Shukla
- Department of Pediatric Surgery, SMS Medical College Jaipur, Rajasthan, India
| |
Collapse
|
6
|
Parelkar SV, Patil SH, Sanghvi BV, Gupta RK, Mhaskar SS, Shah RS, Tiwari P, Pawar AA. Video-Assisted Thoracoscopic Surgery for Pediatric Empyema by Two-Port Technique: A Single-Center Experience with 167 Consecutive Cases. J Indian Assoc Pediatr Surg 2017; 22:150-154. [PMID: 28694571 PMCID: PMC5473300 DOI: 10.4103/jiaps.jiaps_167_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background/Purpose: The aim of our study is to determine efficacy, safety, and feasibility of video-assisted thoracoscopic surgery (VATS) in childhood empyema with a technique of only two ports and open instruments at a tertiary care center in India. Methods: This is a retrospective study of patients below 18 years, with empyema presenting to the Department of Pediatric Surgery of a Tertiary Care Referral Hospital in India, over a period of 9 years who underwent VATS decortication. Only two ports with open surgical instruments were used. The patients were assessed on the basis of mean duration of preoperative symptoms, duration of surgery, average blood loss, postoperative pain relief, complications, and need for redo surgery. Results: A total of 97 patients underwent primary VATS decortications without inserting an intercostal drainage (ICD) tube and 70 patients as a secondary procedure after ICD tube was inserted. Mean duration of symptoms was 11 days. The average blood loss during surgery was estimated to be 170 cc. The mean duration of surgery was 90 min. The most common postoperative complication was air leak seen in 19.16% of patients. Minor leaks usually settled by 24 h. In eight patients, a negative suction had to be applied to the ICD tube for persistent air leak. The average length of postoperative stay was 4 days. Two patients required a repeat open decortication procedure due to nonresolution of symptoms and poor lung expansion after VATS. Patients had minimal pain and excellent cosmetic outcome after VATS. Conclusion: Two-port VATS decortication procedure is as feasible and effective as three-port procedure for decortication with better cosmetic result and pain relief.
Collapse
Affiliation(s)
- Sandesh V Parelkar
- Department of Paediatric Surgery, Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Shalil H Patil
- Department of Paediatric Surgery, Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Beejal V Sanghvi
- Department of Paediatric Surgery, Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Rahul Kumar Gupta
- Department of Paediatric Surgery, Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Satej S Mhaskar
- Department of Paediatric Surgery, Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Rujuta S Shah
- Department of Paediatric Surgery, Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Pooja Tiwari
- Department of Paediatric Surgery, Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Arjun A Pawar
- Department of Paediatric Surgery, Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India
| |
Collapse
|
7
|
Bose K, Saha S, Mridha D, Das K, Mondal P, Das I. Analysis of Outcome of Intraplueral Streptokinase in Pediatric Empyema Thoracis even in Advanced Stages: A Prospective Study. IRANIAN JOURNAL OF PEDIATRICS 2015; 25:e3154. [PMID: 26495096 PMCID: PMC4610336 DOI: 10.5812/ijp.3154] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 07/13/2015] [Accepted: 08/16/2015] [Indexed: 11/20/2022]
Abstract
Background: Empyema thoracis in children causes significant morbidity. Standard treatment of Empyema thoracis includes tube drainage and antibiotics. But the tube drainage often fails. Intrapleural Streptokinase has been used in empyema thoracis with good success rate. Objectives: We evaluated the efficacy of intra-pleural Streptokinase in management of empyema thoracis even in advanced stages. Patients and Methods: A total of 28 patients with empyema thoracis requiring intercostal tube drainage aged zero to twelve years were included in the study who were admitted in Pediatric intensive care unit. 15,000 units/kg of Streptokinase was instilled into the pleural cavity. Response was assessed by clinical outcome, after unclamping and subsequent chest radiography and serial chest ultrasounds. Results: Streptokinase enhanced drainage in all patients with complete resolution of empyema thoracis in 26 patients. Two patients were referred for surgery. Only 7.2% required surgery. Streptokinase was equally effective if started before or after seven days. Conclusions: Intrapleural Streptokinase is the preferred treatment for treating pediatric empyema thoracis even in advanced stages and can avoid surgery.
Collapse
Affiliation(s)
- Kallol Bose
- Assistant Professor, Pediatrics Chittaranjan Seva Sadan Hospital, Kolkata, India
- Corresponding author: Kallol Bose, Assistant Professor, Pediatrics Chittaranjan Seva Sadan Hospital, Kolkata, India. Tel: +91-9836653608, E-mail:
| | - Sudip Saha
- Associate Professor, Pediatrics Chittaranjan Seva Sadan Hospital, Kolkata, India
| | - Dhrubojyoti Mridha
- Assistant Professor, Pediatrics Chittaranjan Seva Sadan Hospital, Kolkata, India
| | - Kallol Das
- RMO cum CT, Pediatrics Chittaranjan Seva Sadan Hospital, Kolkata, India
| | - Piyasi Mondal
- RMO cum CT, Pediatrics Chittaranjan Seva Sadan Hospital, Kolkata, India
| | - Ira Das
- RMO cum CT, Pediatrics Chittaranjan Seva Sadan Hospital, Kolkata, India
| |
Collapse
|
8
|
Pediatric empyema thoracis--role of conservative management. Indian Pediatr 2014; 51:239. [PMID: 24736926 DOI: 10.1007/s13312-014-0365-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
9
|
Decortication in paediatric empyema, comparative study of early vs late intervention. Indian J Thorac Cardiovasc Surg 2013. [DOI: 10.1007/s12055-013-0209-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
|
10
|
|
11
|
Affiliation(s)
- B Mirza
- Department of Paediatric Surgery, The Children's Hospital and The Institute of Child Health, Lahore, Pakistan E-mail:
| | | | | |
Collapse
|