Thoracoscopic decortication: first-line therapy for pediatric empyema

Video-assisted thoracoscopic surgery (VATS) has become a popular and well-refined procedure. It has several advantages over open thoracotomy in terms of invasiveness and cosmetics. The aim of this study is to consider if VATS can serve as primary management for pediatric empyema. Between October 2000 and December 2002, 13 children with empyema receiving VATS were retrospectively reviewed. Of them, 5 had tube thoracostomy before VATS intervention (group T), and 8 had VATS as the initial treatment (group V). Their mean (+/- SD) age of groups V and T were 5.75 +/- 4.43 and 4.0 +/- 1.58 years, respectively. The children of group V had a shorter length of hospital stay (group V 10.7 +/- 3.54 days; group T 28.2 +/- 8.32 days), a shorter period of chest tube drainage (group V 5 +/- 1.87 days; group T 25 +/- 11.08 days), less transfusion (group V 0.4 +/- 0.17 units; group T 0.9 +/- 0.27 units) and less radiation exposure (group V 10.3 +/- 3.49; group T 23.4 +/- 11.64). No mortality was noted in the entire series. We conclude that primary VATS is a safe, effective and definitive method which can serve as first-line therapy for children with empyema.     

Thoracoscopic decortication: a role for video-assisted surgery in chronic postpneumonic pleural empyema

Background. We evaluated a technique of video-assisted thoracoscopic (VAT) decortication of the visceral cortex to reexpand entrapped lung in cases of chronic postpneumonic pleural empyema.

Methods. A prospective cohort study of 48 consecutive patients with multiloculated postpneumonic pleural empyema in whom visceral pleural decortication was required was studied. The effect of VAT decortication on perioperative outcome and factors affecting its success were assessed.

Results. Before the introduction of VAT decortication 12 patients were treated by thoracotomy (group T). In the subsequent 36 patients VAT decortication was attempted with success in 21 (group VS) but lung expansion was not observed in 15 patients (group VF) who required thoracotomy. There was no difference in the age or sex distribution of the 3 groups. Operating time was significantly longer in group T than group VS, mean difference 30.3 minutes (p = 0.001) and postoperative hospital stay was longer in group T than group VS, mean difference 2.9 days (p = 0.004). The success of VAT decortication was not related to either the delay between onset of symptoms or hospital admission and surgery; indeed the operating time decreased with increasing preoperative delay. However, success was related to increasing operative experience (p = 0.001).

Conclusions. VAT decortication is a feasible new technique to achieve lung reexpansion in chronic postpneumonic pleural empyema and has perioperative benefits over thoracotomy.     

Video-assisted thoracoscopic decortication for management of postpneumonic pleural empyema

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) for decortication or debridement in the management of empyema thoracis has increased the available treatment options but requires validation. We present and evaluate our technique and experience with thoracoscopic management of pleural empyema, irrespective of chronicity. METHODS: From May 1, 2000, to April 30, 2002, VATS debridement and decortication in 70 consecutive patients presenting with pleural space infections was performed with endoscopic shaver system. A retrospective review was performed and the effect of this technique on perioperative outcome was assessed. RESULTS: The VATS evacuation of infected pleural fluid and decortication was successfully performed in 65 of 70 patients. The mean duration of preoperative symptoms before referral was 23 +/- 1.8 days. The mean duration of hospitalization before transfer was 13.5 +/- 1.5 days. Blood loss was 330 +/- 200 mL. Intercostal drainage was required for 5 +/- 3 days. The postoperative hospital stay was 5 +/- 0.7 days. There were no operative mortalities. CONCLUSIONS: Video-assisted thoracoscopic decortication with endoshaver system is a simple and effective method in the management of the fibropurulent or organic pleural empyema.     

Failure of tube thoracostomy for post-traumatic empyema: an indication for early decortication.

Post-traumatic empyema has occurred in seven patients despite chest tube drainage and antibiotics. Early pleural decortication resulted in complete recovery of all patients with early discharge from the hospital in most instances. The surgical procedure is technically simple to perform if carried out before the organization of the pleural exudate. Criteria are offered for early decortication of the lung for post-traumatic empyema. They are: 1) Residual air-fluid levels despite chest tube drainage. 2) A clinically deteriorating course with evidence of infection or sepsis arising from the pleura. 3) Pleural restriction with inadequate expansion of the lung resulting in compromised ventilatory function. 4) Failure of chest tubes to allow for resolution of pleural contamination within 14 days of injury. If such indications are employed, excellent results can be anticipated from early decortication of post-traumatic empyema.     

Ideal timing of thoracoscopic decortication and drainage for empyema in children

Background: Thoracoscopy may be required for resistant empyema in children. This study aimed to determine the advantages of thoracoscopy performed soon after diagnosis and its ideal timing. Methods: Between 1996 and 2002, 21 children who had undergone thoracoscopy as an initial procedure or after failure of medical treatment were retrospectively reviewed. The study compared outcome of early thoracoscopy (fewer than 4 days after diagnosis) and that of later surgery. The 4-day limit was chosen for physiopathologic reasons (organization of pleuresia in 72 h). Results: In the early thoracoscopy group, the findings showed shorter operative time (p = 0.03) and postoperative hospital stay (p < 0.05), fewer technical difficulties, fewer complications, and no recourse to other surgical procedures. Conclusions: Early thoracoscopy is greatly beneficial for children with empyema by shortening disease progression. An initial short trial of medical treatment for nonorganising empyema may be attempted on the condition that thoracoscopy not be delayed more than 4 days.     

Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial

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/μL 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 α 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.

Conclusions

There are no therapeutic or recovery advantages between VATS and fibrinolysis for the treatment of empyema; however, VATS resulted in significantly greater charges. Fibrinolysis may pose less risk of acute clinical deterioration and should be the first-line therapy for children with empyema.     

Chronic postpneumonic pleural empyema: comparative merits of thoracoscopic versus open decortication

Objective: We seek to evaluate the comparative merits of thoracoscopic versus open decortication in the surgical management of patients with chronic postpneumonic pleural empyema. Methods: From January 1996 to December 2006, 308 patients (180 males, 128 females, mean age: 56.3 years, range: 17–82 years) with chronic postpneumonic pleural empyema underwent decortication after failure of conservative treatment. Results: Decortication was performed by open thoracotomy in 123 (39.9%) patients (OT) and by videothoracoscopy (VT) in 185 (60.1%). Mortality was 1.29% (4/308). Morbidity was 21.1% (65/308). At 6 months follow-up, three VT patients showed recurrent empyema and underwent re-do surgery by video-assisted-thoracoscopy (VATS) (one patient) or by thoracotomy (two patients). The videothoracoscopic approach showed statistically significant better results in terms of in-hospital postoperative (day 1 and day 7), pain (p < 0.0001), postoperative air leak (p = 0.004), operative time (p < 0.0001), hospital stay (p = 0.020) and time to return to work (p < 0.0001). The analysis of postoperative pain at 6 months follow-up showed no significant differences among the different groups. Conclusions: In the light of our experience, videothoracoscopic decortication appears to be the surgical treatment of choice for chronic postpneumonic pleural empyema even if a multicentric-randomised trial should be performed before videothoracoscopic decortication becomes the gold standard for the treatment of pleural empyema.     

Audit of epidural analgesia in children undergoing thoracotomy for decortication of empyema

Background: Uncertainty remains over the risk of epidural space infectionafter neuraxial blockade in the presence of systemic sepsis.For many years, we have provided epidural analgesia to childrenundergoing thoracotomy for the decortication of parapneumonicempyemas. Following recent publications asserting that epiduralanalgesia is absolutely contraindicated in this situation, weaudited our management. The purpose of this audit was to documentthe effectiveness and the incidence of complications after epiduralinsertion in children with active sepsis from empyemas. Methods: This is a retrospective single-centre audit over a 10-yr period. Results: Forty-six epidurals were performed in children with empyema,and three children were treated with systemic opioids. We foundno infective complications of the epidural space or insertionsites. The epidurals provided excellent analgesia. The incidenceof moderate–severe pain was 18%, and 2% for severe painin the first 24 h after surgery. Minor complications of epiduralanalgesia were uncommon. Two children receiving systemic opioidsfor pain relief suffered respiratory complications, one of whichresulted in a prolonged admission to the intensive care unit. Conclusions: Epidural analgesia provides excellent pain relief after thoracotomyin children with empyema, with a low complication rate. Untilevidence to the contrary emerges, it remains our technique ofchoice for thoracotomy, even in the presence of empyema.