I agree with Dr Spencer that the incidence of the Paediatric Empyema is on the increase and the management of this age-old disease is dependent upon provider-based experiences. Secondly, there is no clear evidence that one modality of management is superior to the other. Therefore giving rise to controversies in the management of this disease. The pathogenesis of the disease (Empyema) is largely ignored while choosing a particular modality of the surgical intervention. As we know that when the disease advances more and more fibrous tissue gets deposited within the purulent exudate giving rise to pleural rinds. This pleural rinds restricts the lung expansion, this process starts after fibro-purulent phase when fibrinous and not fibrous adhesions exists causing loculations. While in later phase (the organizational phase) of the empyema fibrosis occurs restricting the lung expansion.
The objection I have is the use of the word early decortication. I think what author means is early debridement of the pyogenic material from the empyema cavity in the fibro-purulent phase. Some reports mentions the use Video-assisted thoracoscopic (VAT) and early decortication in the management of empyema. It is impossible to perform VAT decortication of pleural rinds, It requires formal thoracotomy to do real decortication. There is usually very little plane between firm to hard fibrous tissue restricting the lung to pass a thoracoscope. The inflamed tissue bleeds heavily hampering the vision. It is not question of experience, as we have done a number of early VAT which is definitely the way forward in reducing morbidity, risk of developing chronic empyema and hospital stay in these children. Again I feel that Fibrinolytics fail in some children because it is used late in the developing empyema process when fibrosis has commenced. Fibrinolytics is only useful in early in exudative and early fibro-purulent phases. So in essence there could be a place for all the surgical interventions only if applied to the appropriate stage of empyema. The aim of any therapy should be early intervention, that results in adequate drainage and complte expansion of lung, thus avoiding Decortication that is the excision of the pleural rinds which carries high morbidity and even mortality.