Original article
Thoracoscopy in pediatric pleural empyema: a prospective study of prognostic factors

https://doi.org/10.1016/j.jpedsurg.2006.05.066Get rights and content

Abstract

Purpose

The indications for thoracoscopy remain imprecise in cases of pleural empyema. This study aimed to identify preoperative prognostic factors to help in the surgical decision.

Methods

From 1996 to 2004, 50 children with parapneumonic pleural empyema underwent thoracoscopy either as the initial procedure (n = 26) or after failure of medical treatment (n = 24). Using multivariate analysis, we tested the prognostic value of clinical and bacteriological data, the ultrasonographic staging of empyema, and the delay before surgery. Outcome measures were technical difficulties, postoperative complications, time to apyrexia, duration of drainage, and length of hospitalization.

Results

The clinical and bacterial data did not significantly predict the postoperative course. Echogenicity and the presence of pleural loculations at ultrasonography were not independent significant prognostic factors. A delay between diagnosis and surgery of more than 4 days was significantly correlated (P < .05) with more frequent surgical difficulties, longer operative time, more postoperative fever, longer drainage time, longer hospitalization, and more postoperative complications, such as bronchopleural fistula, empyema relapse, and persistent atelectasia.

Conclusion

The main prognostic factor for thoracoscopic treatment of pleural empyema is the interval between diagnosis and surgery. A 4-day limit, corresponding to the natural process of empyema organization, is significant. The assessment of loculations by ultrasonography alone is not sufficient to predict the postoperative course.

Section snippets

Patients

From September 1996 to December 2004, 50 children with pleural empyema were admitted to our department. The diagnosis was confirmed in all cases by bacteriological or biochemical study of liquid sample [11] (lactate dehydrogenase >1000 IU/L, glucose <40 mg/dL) and surgical findings (fibrin organization, purulent pleural fluid). Seven patients were enrolled retrospectively in this study, and 43, prospectively.

We recorded the following data: age, sex, and clinical findings; chronology of initial

Results

A marked increase in the incidence of empyema has been observed in our institution since 1996 (Fig. 1).

Discussion

An increase in the incidence of empyema has been reported since 1995, but the etiology is still largely unknown [13]. Although various therapeutic choices for pediatric empyema have been reported to be successful (chest tube drainage [14], thoracotomy [15], thoracoscopy [16], fibrinolytics [4], [5]), the aim of this work was to highlight the earliness of surgical treatment as the most favorable prognostic factor. To ensure the homogeneity of the study group, all patients underwent

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