Current indications for decortication in the treatment of empyema in children

doi:10.1016/S0022-3468(87)80009-X

Journal of Pediatric Surgery

Volume 22, Issue 1, January 1987, Pages 28-33

https://doi.org/10.1016/S0022-3468(87)80009-X Get rights and content

Although most children with empyema respond to antibiotics and pleural drainage, a recognizable number fail to improve. This study reviews experience with ten children over the past 7 years who have been selected for lung decortication for refractory empyema. Decortication was performed because of lack of clinical improvement despite drainage and multiple antibiotics during an average 20-day preoperative hospitalization. Responsible organisms included β-hemolytic Streptococcus, Streptococcus pneumoniae, and Hemophilus influenzae. A computerized tomographic (CT) scan of the chest was performed in the last eight patients and showed at least a 50% limitation of lung expansion by the products of the empyema in each case. Following decortication, chest tubes were removed, antibiotics stopped, and temperature and white blood cell count returned promptly to normal. The advantages of early decortication in selected patients with empyema who do not respond to antibiotics and drainage include low morbidity, shorter hospitalization, and excellent long-term results.

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2014, Spectrochimica Acta - Part A: Molecular and Biomolecular Spectroscopy
In the present study, the silver nanoparticles were synthesized using a solution combustion method with urea as fuel. The prepared silver nanoparticles show an FCC crystalline structure with particle size of 59 nm. FESEM image shows the prepared silver is a rod like structure. The surface-enhanced Raman scattering (SERS) spectrum indicates that the N-(1-(2-chlorophenyl)-2-(2-nitrophenyl)ethyl)-4-methylbenzenesulfonamide (CS) molecule adsorbed on the silver nanoparticles. The spectral analysis reveals that the sulfonamide is adsorbed by tilted orientation on the silver surface. The Hatree Fock calculations were also performed to predict the vibrational motions of CS. This present investigation has been a model system to deduce the interaction of drugs with DNA.
Treatment of loculated parapneumonic empyema. Video assisted thoracoscopy or fibrinolytics?
2011, Anales de Pediatria
El tratamiento ideal del empiema paraneumónico no está determinado. El objetivo del estudio es comparar la evolución del derrame paraneumónico tabicado según el tratamiento inicial, videotoracoscopia (VATS) o drenaje con fibrinolíticos (DF).
Revisión retrospectiva. Pacientes ingresados con el diagnóstico de derrame paraneumónico entre enero de 2001 y julio de 2008. Los derrames complicados (según la ecografía) fueron tratados con drenaje y uroquinasa (DF) o con videotoracoscopia (VATS), dependiendo del cirujano responsable. Las variables analizadas fueron: el número de días hospitalizado tras la intervención, número de días totales de hospitalización, días con drenaje, días de fiebre tras la intervención y fracasos del tratamiento.
Se atendieron 121 pacientes. Diecisiete pacientes fueron excluídos del análisis por tratarse de derrames paraneumónicos simples. De los 104 analizados, 47 fueron tratados con drenaje y uroquinasa y 57, con videotoracoscopia. No hubo diferencias significativas entre ambos grupos en la estancia hospitalaria (mediana 12 vs 12 días) ni estancia post-operatoria (mediana 10 vs 9 días). Se encontraron diferencias en los días de drenaje (mediana grupo DF 5 días, VATS, 4 días, p < 0,05) y en los días de fiebre post-operatoria (mediana 3 vs 2 días, p < 0,05). El 22% de los pacientes precisó de una reintervención (14 del grupo DF y 9 del grupo VATS, p = 0,09)
Los resultados de la VATS frente al DF como tratamiento inicial del empiema tabicado son muy similares. Parece existir una mayor tasa de fracasos con necesidad de reintervención en aquellos casos tratados con inicialmente con uroquinasa, aunque no ocasionan un aumento significativo de la estancia hospitalaria de los pacientes.
There is no consensus regarding the ideal treatment of loculated parapneumonic empyema (PPE).
The aim of this study is to compare the effectiveness of drainage plus urokinase (DF) with video-assisted thoracoscopy (VATS).
Retrospective review. Patients admitted with a PPE between January 2001 and July 2008. Loculated empyema was diagnosed by chest ultrasound and patients were treated with DF or VATS depending on the attending surgeon. Compared variables were: post-operative stay, total hospital stay, days of tube thoracostomy, post-operative fever and treatment failure.
One hundred and twenty one patients were admitted with the diagnosis of PPE. Seventeen patients were excluded from analysis because of simple parapneumonic effusions. Of the 104 patients included in the study, 47 were treated with urokinase and 57 with videothoracoscopy. No statistically significant differences (P > .05) were found between the median values in the DF and VATS groups for hospital stay (median 12 vs 12 days) or post-operative stay (median 9 vs 9 days). There were differences in duration of tube thoracostomy (median DF group 5 days, VATS, 4 days, P < .05) and in the post-operative fever (median 3 vs 2 days, p < 0,05).Twenty two per cent of children needed a second procedure (14 patients of DF and 9 of VATS group, P = .09).
According to our experience, the results of DF and VATS for the treatment of loculated parapneumonic empyema are similar. Although there are no statistical differences, there seems to be a higher rate of failure, with the need of more procedures in the DF group. This difference does not affect the average total hospital stay.
Does VATS Provide Optimal Treatment of Empyema in Children? A Systematic Review
2004, Journal of Pediatric Surgery
The surgical literature is replete with studies describing methods of treatment for pediatric empyema. The purpose of this report was to perform an evidence-based review of the literature to determine the most effective and appropriate treatment for empyema in infants and children.
The MEDLINE database was searched for English- and Spanish-language articles published from 1987 through 2002 on the treatment of thoracic empyema in children. Additional unpublished data were obtained by contacting individual study authors. There were no multiinstitutional prospective studies; all were retrospective, institutional series. A true meta-analysis could not be performed because of inherent institutional bias and variability in outcome measures among studies. A Kruskal-Wallis nonparametric test was used to compare methods detailed in the individual studies.
Forty-four retrospective studies with a total of 1,369 patients were available for analysis. Four treatment strategies were compared: chest tube drainage alone (16 studies, 611 patients), chest tube drainage with fibrinolytic instillation (10 studies, 83 patients), thoracotomy (13 studies, 226 patients), and video-assisted thoracoscopic decortication (VATS; 22 studies, 449 patients). Outcome measures common to the majority of studies included length of stay, fever duration, l of antibiotic therapy duration, and duration of chest tube drainage. Patients undergoing early VATS or thoracotomy had shorter length of stay (P = .003). There was a trend for shorter duration of postoperative fever compared with chest tube alone or with fibrinolytic therapy, but this did not reach statistical significance (P = .055). There was no statistical difference in chest tube duration between methods. There was no trend correlating antibiotic use with treatment methods, length of hospital stay, duration of fever, or length of chest tube requirement.
Early VATS or thoracotomy leads to shorter hospitalization. The duration of chest tube placement and antibiotic use is variable and does not correlate with treatment method. A carefully designed, multiinstitutional, randomized study would lead to the development of evidence-based standards that may optimize the treatment of thoracic empyema in children.
Current issues in the diagnosis and management of pediatric empyema
2002, Seminars in Pediatric Infectious Diseases
Citation Excerpt :
If clinical suspicion for an effusion is high, further investigation is warranted. CT frequently is used as a diagnostic tool to evaluate effusions to determine whether they have progressed beyond the exudative stage to fibrinopurulent or organized empyema.12,14,18-20,28,29 CT provides detailed images of the pleural cavity and is especially useful when chest film shows a “white-out” or complete opacification of the lungs, which renders differentiating among free-flowing effusions, loculations, and pleural thickening difficult.8,12
Empyema is a rare but recognized complication of bacterial pneumonia in children. The incidence of empyema may be rising as vaccination practices and antibiotic prescribing practices promote the emergence of more virulent and resistant organisms. Diagnostic methods vary widely, from thoracentesis to plain radiographs to detailed computed tomography scans. Treatment practices also vary, with some practitioners preferring medical treatment, others employing chest tube drainage or fibrinolytic therapy, and still others aggressively pursuing surgical options. Further study is needed to define the ideal management of empyema. The authors review the current literature and propose an updated management algorithm that incorporates accepted practices as well as emerging trends in diagnosis and management of empyema. Copyright 2002, Elsevier Science (USA). All rights reserved.
Empyema: Development of a critical pathway
2002, Seminars in Pediatric Surgery
Over the past 20 years at the authors' institution, the management of empyema has evolved. The authors recently have developed a critical pathway in an effort to facilitate diagnosis, guide therapy, and reduce cost. Currently, the average length of stay using this pathway is 4 to 5 days with decreased cost compared to the historic length of stay and a national children's hospital database. The authors review steps to develop a critical pathway as well as discuss their pathway for empyema management.
Experience with video-assisted thoracoscopic surgery the management of complicated pneumonia in children
2001, Journal of Pediatric Surgery
Citation Excerpt :
Open debridement, performed under direct vision, requires full thoracotomy, disrupts the integrity of the chest wall, and its sequelae are less well tolerated. The operation can be bloody at times,2 depending on the timing of intervention, requiring higher rate of blood transfusion as is also the case in our series. There is more prolonged air leak when the peel is removed and may result in greater parenchymal loss.
Purpose: The aim of this study was to assess the impact of video assisted thoracoscopic surgery (VATS) in the management of empyema in children. Methods: This report involves cases of complicated pneumonia in children requiring surgical intervention after failure of medical treatment with antibiotics, with or without drainage from November 1997 to October 1999. The impact of VATS has been studied prospectively from October 1998 when VATS was introduced. The results have been compared with the previous year when similar cases were dealt with open thoracotomy. These 2 groups of patients with VATS (V) or without VATS (O) were studied for their progress in hospital and the final outcome. Results: A total of 39 immunocompetent children with community-acquired pneumonia were studied. There were 17 cases in O and 22 in V. There were 2 conversions to open thoracotomy in V. Both of these cases required resection of the lung parenchyma for severe necrosis and bronchopleural fistula. The mean age in years was 5.3 (O) and 4.9 (V). Parameters that were significantly less in V compared with O include timing of referral (O, 13.6 days; V, 5.3 days), number of lung resections (O, 8; V, 2), blood transfusion (O, 14; V, 2), analgesia requirements (O, 7.8 days; V, 2.9 days), postoperative length of stay in hospital (O, 10.4 days; V, 4.6 days), time to become normothermic (O, 5.6 days; V, 1.7 days); and time to removal of chest drains (O, 6.0 days; V, 2.7 days). Cosmesis is superior in cases of VATS compared with open thoracotomy. All the children recovered well on follow-up with resolution of symptoms and no recurrences. Conclusions: (1) VATS has ushered in a new era of hope for patients with complicated pneumonia. (2) Thoracotomy, lung resections, and the attending morbidity rate have decreased. (3) Patients are being referred earlier by the physicians because the management protocol is changing. J Pediatr Surg 36:316-319. Copyright © 2001 by W.B. Saunders Company.

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^*: Presented before the 17th Annual Meeting of the American Pediatric Surgical Association, Toronto, Ontario, May 14–17, 1986.

¹: From the Division of Pediatric Surgery, Massachusetts General Hospital, Boston, and the Department of Pediatric Surgery, Children's Hospital National Medical Center, Washington, DC.

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Current indications for decortication in the treatment of empyema in children*

J Pediatr

J Thorac and Cardiovasc Surg

J Pediatr Surg

Ann Thorac Surg