Although tube thoracostomy with fibrinolytic agents and video-assisted thoracoscopic (VATS) decortication are relatively equivalent in the treatment of empyema with regard to time to patient defervescence and hospital discharge, the potential for greater benefit with VATS decortication in the setting of advanced empyema has not been explored fully. This paper describes our transition from a policy of drainage and antibiotics to primary operative management with VATS. We wanted to assess the safety and efficacy of primary operative management as a first-line treatment for advanced disease.
A retrospective review was conducted of 25 patients treated for stage 3 or 4 empyema. The primary endpoints were morbidity and death. The secondary endpoints were conversion to an open procedure, time to defervescence, and length of hospital stay.
The morbidity rate was 16% with no deaths. No patient required conversion to open decortication. The mean time to defervescence was 3.2 days, and on average, patients were discharged on postoperative day 9. Patients were discharged home earlier when managed primarily with VATS.
Video-assisted thoracoscopic decortication is a safe and effective treatment for pediatric stage 3 or 4 empyema.
[Show abstract][Hide abstract] ABSTRACT: Purpose: Management of empyema has been debated in the literature for decades. Although both primary video-assisted thoracoscopic surgery (VATS) and tube thoracostomy with pleural instillation of fibrinolytics have been shown to result in early resolution when compared to tube thoracostomy alone, there is a lack of comparative data between these modes of management. Therefore, we conducted a prospective, randomized trial comparing VATS to fibrinolytic therapy in children with empyema. Methods: After Institutional Review Board approval, children defined as having empyema by either loculation on imaging or more than 10,000 white blood cells/mu L were treated with VATS or fibrinolysis. Based on our retrospective data using length of postoperative hospitalization as the primary end point, a sample size of 36 patients was calculated for an alpha of .5 and a power of 0.8. Fibrinolysis consisted of inserting a 12F chest tube followed by infusion of 4 mg tissue plasminogen activator mixed with 40 mL of normal saline at the time of tube placement followed by 2 subsequent doses 24 hours apart. Results: At diagnosis, there were no differences between groups in age, weight, degree of oxygen support, white blood cell count, or days of symptoms. The outcome data showed no difference in days of hospitalization after intervention, days of oxygen requirement, days until afebrile, or analgesic requirements. Video-assisted thoracoscopic surgery was associated with significantly higher charges. Three patients (16.6%) in the fibrinolysis group subsequently required VATS for definitive therapy. Two patients in the VATS group required ventilator support after therapy, one of whom required temporary dialysis. No patient in the fibrinolysis group clinically worsened after initiation of therapy.
Journal of Pediatric Surgery 02/2009; 44(1):106-11; discussion 111. DOI:10.1016/j.jpedsurg.2008.10.018 · 1.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There are approximately 60,000 new cases of postpneumonic empyema every day in the United States. Usually the fibrinopurulent stage of this complication has been treated by either tube thoracostomy or thoracotomy and debridement. According to the literature, thoracoscopic treatment has not been used often for this disease.
Sixty-four cases of postpneumonic fibrinopurulent empyema were operated on at our institution: 33 cases (group I) by means of a formal thoracotomy and 31 cases (group II) by thoracoscopy. In the thoracoscopic subset the data were collected prospectively since 1992. These results were compared with those of a historical series treated by thoracotomy between 1985 and 1991. Both populations were similar in terms of age (mean, 49 years), number of cases (33/31), sex (2.1 male/female), and comorbid status.
Mean preoperative length of the medical management (11.5 versus 17 days) (p = 0.03) and chest tube removal (4.3 versus 6.1 days) were shorter in group II than in group I (p = 0.02). Morbidity and mortality were identical: one death and five complications in each group. Mean operative time was similar in both groups, and hospital stay was shorter in the video-assisted thoracic surgery group (6.8 versus 11.2 days) (p = not significant). Three patients from group II needed utilitary thoracotomies for debridement completeness (10% conversion rate).
We conclude that video-assisted thoracic surgical treatment has the same rate of success as open thoracotomy but offers substantial advantages over thoracotomy in terms of resolution of the disease, hospital stay, and cosmesis. A prospective and randomized study is needed to confirm the findings of this nonrandomized initial experience.
The Annals of Thoracic Surgery 07/1996; 61(6):1626-30. DOI:10.1016/0003-4975(96)00194-4 · 3.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: During a 19-month period, seven children with empyema underwent thoracoscopy. The average age was 7.5 years (range, 3 to 15 years) and the duration of illness before surgery 16.5 days (range, 7 to 42 days). All patients received preoperative antibiotics, underwent ultrasound or CT scan and thoracentesis. Two patients had preoperative intercostal tube drainage. Indications for operations were lack of response to antibiotics of loculation of pleural fluid on imaging. All procedures were performed under general anesthesia with a single lumen tube.
Thoracoscopy allowed for good access and complete clearance in two patients. In the remaining patients, thoracoscopy failed to clear the disease because of difficulty with access, instrumentation, and clearance of thick debris. These patients underwent thoracotomy with two requiring decortication.
This experience suggests that even in the early stage of empyema formation, thoracoscopy is not as effective as thoracotomy. Larger experience and studies are required to define the place of thoracoscopy in the management of childhood empyema.
Journal of Pediatric Surgery 06/1998; 33(5):708-10. DOI:10.1016/S0022-3468(98)90192-0 · 1.39 Impact Factor
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