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Evolving experience in the management of empyema thoracis
K R Shankar1, S E Kenny, B O Okoye
1Department of Paediatric Surgery, Alder Hey Children's Hospital and The University of Liverpool, UK.
Insights
Early thoracotomy is recommended for paediatric empyema thoracis. Delayed surgery, even after initial conservative management, led to significant complications, highlighting the need for prompt surgical intervention in children with empyema.
Area of Science:
- Pediatric Surgery
- Thoracic Medicine
- Diagnostic Imaging
Background:
- Management of paediatric empyema thoracis lacks consensus.
- Evolving clinical presentation, management strategies, and outcomes require analysis.
Purpose of the Study:
- To analyze changes in paediatric empyema thoracis over time.
- To identify factors influencing diagnosis, management, and adverse outcomes.
Main Methods:
- Retrospective analysis of 47 paediatric patients from 1980-1997.
- Categorization into conservative management (antibiotics, tube thoracostomy) and thoracotomy groups.
- Utilized ultrasound for diagnosis and staging.
Main Results:
- Ultrasound increasingly guided management, identifying loculated fluid.
- 80% of patients initially treated conservatively eventually required thoracotomy.
- Delayed thoracotomy was associated with significant complications like recurrent empyema and lung abscess.
Conclusions:
- An aggressive early thoracotomy approach is favored due to better outcomes.
- Ultrasound findings of loculated fluid influence the decision for early surgery.
- Further randomized trials are needed to determine optimal paediatric empyema therapy.
Abstract:
The optimal management of paediatric empyema thoracis remains controversial. The objective of the study was to analyse evolving experience in clinical presentation, management, outcome and factors contributing to adverse morbidity in thoracic empyema. Forty-seven patients presenting to a paediatric surgical centre were studied in three consecutive 6-y periods during 1980-97 to compare any change in the pattern of disease influencing diagnosis and management. Patients were categorized into two treatment groups: (i) conservative management (antibiotics and/or tube thoracostomy), (ii) thoracotomy. The median duration of illness prior to hospital admission was 10 d (range 1-42 d). Ultrasound was increasingly utilized in the diagnosis and staging of empyema and played an important role in directing definitive management. The presence of loculated pleural fluid determined the need for thoracotomy. Sixteen of 20 patients (80%) who were initially treated with thoracocentesis or tube thoracostomy eventually needed thoracotomy. There was a positive shift in management towards early thoracotomy resulting in prompt symptomatic recovery. Significant complications were noted in seven children who had delayed thoracotomy. These included recurrent empyema with lung abscess (n = 2), scoliosis (n = 2), restrictive lung disease (n = 1), bronchopleural fistula (n = 1) and sympathetic pericardial effusion (n = 1). An unfavourable experience with delayed thoracotomy during the study period has led us to adopt a more aggressive early operative approach to empyema thoracis. The decision to undertake thoracotomy has been influenced by the ultrasound findings of organized loculated pleural fluid. Delayed surgery was associated with adverse outcome. Whilst fibrinolytics and thoracoscopy may provide attractive options for early empyema, thoracotomy can hasten patient recovery regardless of the stage of disease. Prospective randomized trials are required to assess the ideal therapy for childhood empyema.