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The controversial role of decortication in the management of pediatric empyema
1Department of Surgery, University of New Mexico Hospital, Albuquerque 87106.
Insights
Open surgical drainage, including decortication, is an effective treatment for pediatric pleural empyema when initial antibiotic and tube drainage fail. This approach offers rapid improvement and low risk, challenging its role as a last resort.
Area of Science:
- Pediatric Surgery
- Thoracic Surgery
- Infectious Diseases
Background:
- Pediatric pleural empyema management often involves prolonged antibiotics and chest tube drainage.
- Open surgical procedures for pediatric empyema are generally considered controversial.
Purpose of the Study:
- To evaluate the safety and efficacy of a selective open surgical drainage approach for pediatric pleural empyema.
- To assess the role of decortication in managing organizing empyema in children.
Main Methods:
- A retrospective review of 22 children with pleural empyema treated with a selective open drainage strategy.
- Drainage method (limited decortication or decortication) was chosen based on the empyema's pathologic phase.
- Patients received initial antibiotics and closed tube drainage for 3-5 days before considering open drainage.
Main Results:
- Open drainage led to dramatic clinical improvement, with most children afebrile by postoperative day 3 and discharged by day 10.
- No deaths occurred; 14% experienced complications (air leak or infection).
- Anaerobic bacteria (36%) were associated with rapid empyema organization and the need for decortication.
Conclusions:
- Decortication is a low-risk, effective definitive therapy for pediatric pleural empyema, especially in organizing cases.
- A selective open drainage approach can be considered earlier in treatment, not solely as a last resort.
- Prompt surgical intervention can improve outcomes in pediatric empyema.
Abstract:
Open surgical procedures for pleural empyema remain controversial in children. The pediatric literature generally recommends a prolonged trial of antibiotics and closed tube thoracostomy drainage. We report a favorable experience with a selective approach to open drainage in 22 children, many of whom had an empyema already organizing at admission. Open drainage was considered in children whose conditions failed to improve after 3 to 5 days of therapy with antibiotics and closed drainage. The method of drainage was selected according to the pathologic phase of the empyema: five children with fibrinopurulent empyema were successfully managed by limited decortication, and 17 with organizing empyema received decortication. Clinical improvement was usually dramatic; most of the children became afebrile by postoperative day 3 and were discharged by postoperative day 10. There were no deaths. Three children (14%) had complications of postoperative air leak or infection. Streptococcus pneumoniae (5) and Hemophilus influenzae (3) were the most common single pathogens. The presence of anaerobic bacteria in 8 of 22 children (36%) was associated with rapid organization of the empyema and the need for decortication. Decortication procedures have a low risk and are effective in children with empyema. They should be considered as definitive therapy, rather than as a last resort.