Declining frequency of thoracoscopic decortication for empyema — redefining failure after fibrinolysis

This retrospective study demonstrates that primary fibrinolytic therapy with tPA has nearly eliminated the need for thoracoscopic decortication in pediatric empyema, with VATS rates declining from 4.2% to 0% over 33 months. By raising the threshold for surgical intervention and optimizing nonoperative protocols, most children can avoid operation without prolonging hospital stay.