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Declining frequency of thoracoscopic decortication for empyema - redefining failure after fibrinolysis

Tolulope A Oyetunji1, Robert M Dorman2, Wendy Jo Svetanoff2

  • 1Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, USA; School of Medicine, University of Missouri-Kansas City, 2411 Holmes St, Kansas City, MO 64108, USA.

Journal of Pediatric Surgery
|January 28, 2020
PubMed

Insights

Pediatric empyema treatment with fibrinolysis (tPA) rarely requires surgery. This approach, utilizing tissue plasminogen activator, significantly reduced the need for video-assisted thoracoscopic surgery (VATS) decortication over time.

Area of Science:

  • Pediatric Thoracic Surgery
  • Pulmonology
  • Critical Care Medicine

Background:

  • Primary fibrinolysis is the standard of care for pediatric empyema at our institution.
  • An initial study showed a 16% rate of thoracoscopic decortication following fibrinolysis.
  • This study evaluates the protocol's maturation and its impact on surgical intervention rates.

Purpose of the Study:

  • To determine the frequency of operative intervention in children with empyema treated with fibrinolysis.
  • To assess the efficacy of the refined fibrinolysis protocol in reducing the need for surgical decortication.

Main Methods:

  • Retrospective review of pediatric empyema patients (2014-2019).
  • Inclusion criteria: tissue plasminogen activator (tPA) therapy with or without video-assisted thoracoscopic (VATS) decortication.
  • Exclusion criteria: other indications for tube thoracostomy or VATS.

Main Results:

  • 48 patients included; median age 4.5 years; median length of stay 8 days.
  • No patients underwent primary VATS; 7 patients (14.6%) had chest tube replacement without VATS.
  • VATS rate decreased from 4.2% to 0% over the study period, indicating improved nonoperative management.

Conclusions:

  • Thoracoscopic decortication is infrequently required for pediatric empyema.
  • Elevating the threshold for surgical intervention and employing nonoperative measures effectively avoids surgery in most cases.
  • This approach does not prolong in-hospital length of stay.
Abstract

Keywords:
EmpyemaFibrinolysisFibrinolytic therapyPediatricsVATS

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