Intrapleural Fibrinolytic Therapy Versus Video-Assisted Thoracoscopic Surgery, as the Initial Treatment Modality, in...

Intrapleural fibrinolytic therapy (IPFT) is frequently used in empyema thoracis as the initial treatment modality. However, some pediatricians prefer video-assisted thoracoscopic surgery (VATS). The optimal strategy is unclear.

This systematic review was undertaken to compare IPFT versus VATS as the initial treatment modality in children with empyema thoracis, to support an evidence-based guideline recommendation.

Literature search was conducted in seven electronic databases and four trial registries, seeking randomized controlled trials (RCT) comparing IPFT versus VATS in children with empyema thoracis. The critical outcomes were failure of therapy, need for thoracotomy, clinical outcomes within three months of discharge, and serious adverse events. Other outcomes were mortality, clinical outcomes at ≥ 12mo of discharge and pulmonary function after discharge. Methodological quality was assessed using Cochrane RoB 2 tool. GRADE was used to assess the overall certainty of evidence.

Amongst 7,738 citations, five RCTs were included. Failure of therapy (4 studies, n = 235) was comparable between IPFT versus VATS; OR 1.01, 95% CI 0.46, 2.21; I² 9%. Likewise, the need for thoracotomy (3 studies, n = 199) was also comparable; OR 0.24, 95% CI 0.06,1.06; I² 0%; and also, the serious adverse events were similar (4 studies, n = 235); OR 0.67, 95% CI 0.24,1.90; I² 0%. However, IPFT was associated with longer hospital stay, but lower cost. Risk of bias assessment identified concerns related to the randomization process, outcome measurement, and selective reporting in some studies. The overall certainty of evidence was very low.

Very low certainty evidence from five RCTs did not identify a clear difference between IPFT and VATS as the initial treatment modality in children with empyema thoracis.