Surgical management and outcome analysis of stage III pediatric empyema thoracis

Report of 125 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.

All the children who underwent open decortication for stage III empyema thoracis during the study period were included. Preoperative workup included hemogram, serum protein, chest radiographs and contrast-enhanced computed tomographic (CECT) scan of the chest.

One hundred and twenty-five patients (81 males, 44 females) (age 3 months-12 years, mean 4.9 years) were operated during a 4.5-year period. Among them, two children underwent bilateral thoracotomies. Also, 81.6% patients were referred 3 weeks after the onset of disease (mean duration 9 weeks). Intercostal chest drainage (ICD) had been inserted in (119) 95% cases. Thickened pleura, multiloculated pus and lung involvement were invariably seen on CECT scan. Bronchopleural fistula was present in 10 patients and empyema necessitatis in 2. Decortication, removal of necrotic tissue and closure of air leaks was performed in all the patients. Necrotizing pneumonia was seen in (35) 27.5% cases. Mean duration of postoperative ICD was 7 days. Follow-up ranged from 3 months to 4 years (mean 12 months). There was no mortality. Six patients had proven tuberculosis.

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. Only 18% presented within the early period of the disease. Meticulous open surgical debridement gives gratifying results. The status of the lung at the end of surgery is a major prognostic factor.