Chest
Volume 118, Issue 1, July 2000, Pages 24-27
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Clinical Investigations: Techniques
Thoracoscopic Decortication as First-Line Therapy for Pediatric Parapneumonic Empyema: A Case Series

https://doi.org/10.1378/chest.118.1.24Get rights and content

Study objectives

Previous articles have promoted the early use of thoracotomy and decortication for refractory empyema. This study examines thoracoscopy and decortication at the time of initial chest tube placement in pediatric patients with parapneumonic empyema.

Design

We reviewed the medical records of 16 consecutive patients who were children with parapneumonic empyema.

Results

Thirteen children (group 1) underwent thoracoscopic decortication and tube thoracostomy as their initial operative procedures; 3 children (group 2) had tube thoracostomy alone. In both groups, chest tubes were removed prior to their discharge to home. The mean (± SD) operative time for thoracoscopy was 81 ± 19 min with no complications. On average, chest tubes were removed by postoperative day 4. The mean time to discharge was 8.3 days. Two children eventually required lobectomy. The mean operative time for chest tube placement alone was 21 ± 3 min. Children required chest tube drainage for an average of 12.3 days. The mean time to discharge was 16.6 days. Two patients required a total of five additional operative procedures, including two additional chest tube placements, two open decortications, and one lobectomy.

Conclusions

Thoracoscopic decortication is effective in the early treatment of pediatric parapneumonic empyema. It facilitates visualization, evacuation, and mechanical decortication of the pleural space with no additional morbidity and may lead to reduced time for chest tube drainage, shorter hospitalization, and more rapid clinical recovery.

Section snippets

Patients and Data Collection

Sixteen children with parapneumonic empyema were treated by the authors between November 1997 and August 1998. Patients presenting with pneumonia (characterized by fever, cough, chest pain, and leukocytosis) were initially evaluated by routine chest radiograph. A presumptive diagnosis of parapneumonic empyema was made in those patients with radiographic evidence of infiltrates combined with a large pleural effusion, unbalanced air-fluid levels, or multiple loculations. Chest CT scanning was

Results

Of the 16 children treated for parapneumonic empyema, 9 were boys and 7 girls. All previously had been healthy, although two children had experienced recurrent bouts of otitis media. Ten children presented during the winter months. The average age was 5 years (range, 1 to 16 years). Thirteen children presented with fever. All 16 patients had leukocytosis. Unilateral effusion was present on all admission chest radiographs. Each child received broad-spectrum IV antibiotics.

Discussion

Since the clinical entity of empyema was first described, its optimal treatment has been continually debated.9 With the development of more potent antibiotics and the advent of newer techniques for pleural drainage, therapy has become more effective and less morbidity has occurred.

Although tube thoracostomy is effective in the treatment of many early empyemas, 18 to 60% of children do not respond to closed drainage.3, 10 Most children do not present during the first 24 to 72 h of empyema

Conclusion

Although our study is limited by its small size and lack of a randomized control group, we believe that parapneumonic empyema in children can be expeditiously diagnosed and treated by thoracoscopy and decortication when the child initially receives the anesthetic for chest tube placement. Thoracoscopy allows for the effective drainage of the pleural space with no additional morbidity and may result in a shorter hospital stay than tube thoracostomy alone. A larger, prospective study is warranted

ACKNOWLEDGMENT

The authors thank Ms. Cissy Moore-Swartz for her assistance with the manuscript.

References (17)

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