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Pediatric empyema thoracis management: should the consensus be different for the developing countries?
Gowri Shankar1, Ravindra Sahadev1, Ramesh Santhanakrishnan1
1Department of Pediatric Surgery, Indira Gandhi Institute of Child Heath, Bangalore-29.
Insights
Intrapleural fibrinolytic therapy (IFT) is as effective as video-assisted thoracoscopic surgery (VATS) for treating pediatric stage II empyema in the Indian subcontinent. This study suggests IFT is a viable, cost-effective alternative in developing countries.
Area of Science:
- Pediatric Thoracic Surgery
- Interventional Pulmonology
- Evidence-Based Medicine
Background:
- Pediatric empyema is prevalent in the Indian subcontinent, yet intrapleural fibrinolytic therapy (IFT) remains underutilized.
- Existing literature on IFT for pediatric empyema in developing countries is scarce.
- This study addresses potential epidemiological differences and physician bias influencing treatment choices.
Purpose of the Study:
- To determine the equivalence of fibrinolytic therapy to video-assisted thoracoscopic surgery (VATS) for stage II empyema in children.
- To evaluate treatment efficacy, complications, and cost-effectiveness in a developing country context.
Main Methods:
- A randomized controlled trial comparing IFT and VATS for stage II empyema in children.
- Outcomes assessed included hospital stay duration, therapeutic efficacy, complications, and cost.
- Study type: Randomized controlled trial, treatment study, and cost-effectiveness analysis.
Main Results:
- Successful empyema clearance was high in both groups: 90% for VATS (20 children) and 95.2% for IFT (21 children).
- Median hospital stay was similar (7 days for VATS vs. 8 days for IFT, p=0.24).
- VATS group required significantly more CT scans (p=0.02) and blood transfusions (p=0.000) than the IFT group.
Conclusions:
- Intrapleural fibrinolytic therapy is non-inferior to VATS for treating pediatric stage II empyema in the Indian subcontinent.
- IFT presents a potentially more cost-effective and less resource-intensive option.
- Further multicenter trials with larger sample sizes and standardized protocols are recommended to strengthen findings and reduce bias.
Background:
Despite the available consensus, intrapleural fibrinolytic therapy (IFT) in pediatric empyema is grossly underutilized in the Indian subcontinent where the disease burden is huge. Possible reasons may be epidemiological differences and physician bias. There is a paucity of literature from developing countries on the use of IFT in pediatric empyema thoracis. Hence, this study was undertaken to determine if fibrinolytic therapy is equivalent to video-assisted thoracoscopic surgery (VATS) in treating stage II empyema in children even in developing countries.
Methods:
Consecutive cases of stage II empyema were randomized to receive either IFT or VATS. The outcomes measured were the duration of hospital stay, efficacy of therapy, complications, and cost differences.
Results:
41 children were randomized to either VATS (n = 20) or IFT (n = 21) group. Overall successful clearance of empyema was achieved in 18 out of 20 (90%) children undergoing VATS and 20 out of 21(95.2%) children in fibrinolytic arm. The median length of the hospital stay was 7 and 8 days for VATS and IFT groups respectively (p = .24). Need for CT scan and blood transfusion was significantly higher in the VATS group than IFT group (p = .02 and .000).
Conclusions:
Fibrinolytic therapy is noninferior to VATS in the treatment of stage II empyema in children in the Indian subcontinent. A multicenter trial with larger sample size and uniform, detailed protocols on indications for CT scan, blood transfusions, nutrition status and costs involved will be needed to eliminate institutional bias and to increase the strength of the study.
Study Type:
Randomized controlled study, treatment study and cost effectiveness study.
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