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Thoracic empyema
  1. A Jaffé1,
  2. G Cohen2
  1. 1Consultant and Honorary Senior Lecturer in Respiratory Research, Portex Respiratory Medicine Unit, Great Ormond Street Hospital for Children NHS Trust and Institute of Child Health, Great Ormond Street, London WC1N 3JH, UK
  2. 2Chief of Pediatric Cardiothoracic Surgery and Associate Professor of Surgery, Seattle Children’s Hospital, University of Washington School of Medicine, USA
  1. Correspondence to:
    Dr A Jaffé, Portex Respiratory Medicine Unit, Great Ormond Street Hospital for Children NHS Trust and Institute of Child Health, Great Ormond Street, London WC1N 3JH, UK;
    a.jaffe{at}ich.ucl.ac.uk

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A role for primary video assisted thoracoscopic surgery?

As long ago as 300 BC, Hippocrates commented that a person “with empyemata … shall die on the fourteenth day, unless something favourable supervene”.1 After identifying the affected side he would recommend drainage with a tin tube. However, in the ensuing years, great debate surrounded the benefits of opening the chest. When Napoleon’s surgeon, Dupuytren, developed an empyema in 1835, he was heard to comment that “he would rather die at the hands of God than of surgeons”. He lived 12 days. Over one and a half centuries later the role of the surgeon in the management of empyema remains controversial. This leading article will review the potential role for primary video assisted thoracoscopic surgery (VATS) in thoracic empyema in children.

TREATMENT AIMS IN EMPYEMA

The aim of empyema treatment is to return the lung to normal function. This is achieved by sterilising the pleural cavity with antibiotics, drainage of fluid, and expansion of the lung. There are three stages in empyema formation.2 The first is the exudative stage, during which fibrinous material forms on both pleural surfaces. As more fibrin is deposited, the pleural surfaces may be joined by fibrinous septae which cause the fluid to become loculated. This is the fibrinopurulent stage and may last several weeks. The final stage is the organisational stage, and is characterised by proliferation of fibroblasts on the pleural surfaces, which form an inelastic covering preventing adequate lung expansion (fibrothorax). Early intervention prevents this third stage from developing. Currently the primary treatment options are: antibiotics alone; recurrent thoracocentesis; insertion of chest drain alone or in combination with fibrinolytics; open decortication; or VATS.

THE RATIONALE FOR VATS

Since the 1960s there has been a growing interest in the use of minimally invasive surgery in children. Initial procedures were diagnostic, but with the …

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