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Management of late-stage parapneumonic empyema
Li Ern Chen1, Jacob C Langer, Patrick A Dillon
1Washington University School of Medicine & St Louis Children's Hospital, St Louis, MO, USA.
Insights
Early surgery is best for children with late-stage empyema. Delaying surgical intervention increases hospital stay and procedures, while prompt surgery leads to faster recovery and shorter lengths of stay.
Area of Science:
- Pediatric Surgery
- Thoracic Surgery
- Infectious Diseases
Background:
- Empyema in children often presents late, despite the benefits of early intervention.
- Optimal management strategies for late-presenting empyema require further investigation.
Purpose of the Study:
- To determine the optimal management strategy for children with late-presenting empyema (stage II or III).
Main Methods:
- Retrospective review of 70 children with late-presenting empyema (1990-2000).
- Patients were grouped by management: chest tube (CT) alone, CT followed by surgery, thoracentesis then surgery, or surgery alone.
- Comparison of treatment outcomes including length of stay and need for surgical intervention.
Main Results:
- 73% of patients ultimately required surgical intervention.
- Treatments involving initial chest tube or thoracentesis were associated with longer hospital stays compared to surgery alone.
- Surgery alone resulted in the shortest length of stay (8 days).
- Video-assisted thoracoscopic surgery (VATS) showed a shorter total length of stay than open decortication, despite longer postoperative fever.
Conclusions:
- Over 70% of children with late-presenting empyema require surgery.
- Delaying surgical intervention increases procedures and length of stay.
- Early surgical intervention, particularly surgery alone, is indicated for most children with established empyema to shorten hospital stays and improve outcomes.
Purpose:
Despite the reported value of early video-assisted thoracoscopic surgery (VATS) for empyema, many children are still referred to the surgeon late in the disease process. The authors wished to determine the optimal management strategy for this group of children.
Methods:
Medical records of all children (n = 70) from 1990 to 2000 with late-presenting empyema (stage II or III) were reviewed. Patients were grouped as (G1) successful management with chest tube (CT), (G2) surgery after initial CT, (G3) thoracentesis followed by surgery, and (G4) surgery alone.
Results:
There were no significant differences with respect to age, gender, pleural cultures or fluid analysis. Fifty-one (73%) patients required surgical intervention. Treatment using CT (G1, G2) or thoracentesis (G3) was associated with prolonged length of stay (LOS) when compared with surgery alone (G4; 12 v 8 days). For G2, G3, and G4, rapid clinical improvement and early discharge (6 days) was seen after surgery. For all surgery groups (G2, G3, G4), video-assisted thoracoscopic surgery (n = 19) was associated with a longer postoperative fever (4 v 2 days; P <.05), but a shorter total LOS (12 v 15 days; P <.05) when compared with open decortication (n = 32).
Conclusions:
Over 70% of children with late presenting empyema required surgery, including more than half of the children who received initial chest tube drainage. Delay in surgery was associated with more procedures, more radiographs, and an increased LOS. Despite later intervention, patients undergoing surgery as an initial approach had the shortest length of stay. Early surgical intervention is indicated for most children referred with established empyema.