Do patients with empyema really need a VATS?

Infographic · Jan 2021 · 1 min read

In brief

This retrospective study demonstrates that primary fibrinolysis with tPA can successfully treat pediatric empyema in most cases, reducing VATS decortication rates from 16% to 0% over 33 months. The protocol achieved median 8-day hospital stays while avoiding surgery in 95.8% of patients, challenging routine surgical intervention for empyema.

Primary fibrinolysis with tPA reduced VATS decortication rate to 4.2% overall and 0% in the final 33 months of the study period.
Median treatment required only 3 doses of tPA with 5 days of chest tube drainage, achieving resolution without surgery in 95.8% of cases.
Raising the surgical threshold and maximizing nonoperative management avoided VATS in most pediatric empyema patients without increasing LOS.
Only 14.6% of patients required chest tube replacement, demonstrating high success rate of primary fibrinolysis protocol.
Study supports primary fibrinolysis as standard of care for pediatric empyema, reserving VATS for rare refractory cases.

Written by the GCMD Library team from the infographic.

A colorful infographic with four main sections arranged in a grid layout. The left side features a pink box with an illustration of a child at a computer. The right side contains three boxes in blue, green, and magenta showing patient statistics and outcomes. A dark green box in the bottom right displays the StayCurrent Infographics branding with Cincinnati Children's and Pediatric Surgery logos.

Abstract

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.

The text in the image

Do Kids with empyema really need VATS? | 5-year | Retrospective review of kids diagnosed with empyema who underwent tPA with or without subsequent VATS | Total of 48 patients received a 12 F chest tube and median 3 doses of tPA over 48 hrs. | 14.6% had the chest tube replaced without need for VATS | VATS rate was 4.2% but down to 0% in the last 33 months of the study | StayCurrent INFOGRAPHICS | Source: Children's Mercy Hospital Kansas City, MO | https://pubmed.ncbi.nlm.nih.gov/31983309/

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