Declining frequency of thoracoscopic decortication for empyema - redefining failure after fibrinolysis
Background: Primary fibrinolysis for pediatric empyema has become standard of care at our institution. Early study of our protocol revealed a 16% thoracoscopic decortication rate after primary fibrinolysis. We now report the frequency with which children progress to operation with maturation of the protocol.
Methods: A database of patients diagnosed with empyema between September 2014 and March 2019 was examined. Patients who underwent tissue plasminogen activator (tPA) therapy with or without subsequent video-assisted thoracoscopic (VATS) decortication were included. Patients with additional indications for tube thoracostomy or VATS were excluded.
Results: Forty-eight patients were included. Median age was 4.5 years [IQR 2-9.3]. Median length of stay (LOS) was 8 days [IQR 6-11]. No patients underwent primary VATS. Median days with a chest tube was 5 [IQR 5-6] and median number of doses of tPA was 3 [IQR 3-3]. Seven patients (14.6%) had a chest tube replaced without undergoing VATS. The VATS rate was 4.2% in the first half of this study but 0% in the last 33 months.
Conclusion: Thoracoscopic decortication is rarely necessary in children with empyema. Raising the threshold for surgical intervention and utilizing further nonoperative measures can avoid an operation in most children without increasing in-hospital length of stay.
Level of evidence: IV.
J Pediatr Surg
Empyema; Fibrinolysis; Fibrinolytic therapy; Pediatrics; VATS
Oyetunji TA, Dorman RM, Svetanoff WJ, et al. Declining frequency of thoracoscopic decortication for empyema - redefining failure after fibrinolysis. J Pediatr Surg. 2020;55(11):2352-2355. doi:10.1016/j.jpedsurg.2019.12.023