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Ann Thorac Surg 1995;59:1166-1168
© 1995 The Society of Thoracic Surgeons

Thoracoscopic Debridement of Loculated Empyema Thoracis in Children

Division of Pediatric Surgery, Department of Surgery, St. Louis University School of Medicine, St. Louis, Missouri

Accepted for publication January 23, 1995.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The appropriate management of multiloculated empyema thoracis remains controversial. During a 7-month period, we have managed multiloculated empyema with early thoracoscopic debridement in three consecutive pediatric patients. Chest tubes were removed 7 ± 1 (mean ± standard deviation) days after thoracoscopy and discharge from hospital was on postoperative day 8 ± 1. We suggest that early thoracoscopic debridement of multiloculated empyema thoracis in children is safe and efficacious.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Empyema thoracis in its earliest stage is treated by tube thoracostomy for drainage as an adjunct to appropriate antibiotic therapy directed at the causative organisms. Progression of empyema, with the development of fibrinous adhesions and loculations, makes simple drainage difficult or impossible [1]. The appropriate management at this point in the disease remains controversial.

Continued conservative therapy risks the morbidity of a protracted febrile illness requiring a prolonged hospitalization, prolonged antibiotic treatment, or both. The formation of chronic empyema with subsequent trapping of the lung can occur. Thoracotomy and decortication have been used frequently in the management of children who fail closed tube thoracostomy [2–4]. More recently, other researchers have advocated the use of intrapleural fibrinolytic therapy as a form of chemical debridement for augmenting drainage and for disruption of loculations [5–7].

Thoracoscopic debridement and irrigation of loculated empyema was originally advocated for use in adults [8, 9]. A recent report details an experience with children who developed postpneumonic loculated empyema and were managed with thoracoscopic debridement, adhesiolysis, and placement of drainage tubes under direct visual control [10]. In the present report, we describe the management of three pediatric patients with postpneumonic loculated empyema using this technique.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Three consecutive patients, reviewed retrospectively, treated between December 1993 and July 1994 at The St. Louis University Medical Center (Cardinal Glennon Children's Hospital), presented with pneumonia and empyema that failed management consisting of broad spectrum antibiotics and tube thoracostomy (Table 1). Tube thoracostomy was performed in patients with complicated parapneumonic effusion (pH <7 and lactate dehydrogenase more than 1,000 U/L, or a positive Gram stain) [11].

View larger version (152K): [in this window] [in a new window]   Fig 1. . Plain radiograph demonstrates opacification of the right hemithorax and lower lobar consolidation.

View larger version (115K): [in this window] [in a new window]   Fig 2. . Computed tomographic demonstration of left empyema with loculations and compression of lung parenchyma.

View larger version (120K): [in this window] [in a new window]   Fig 3. . Ultrasound demonstration of multiple loculations within a right pleural empyema (same patient as in Figure 1).

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
All patients were confirmed radiographically to have multiloculated collections not drained by the previously placed chest tubes. Persistent fever and pleural effusion despite tube thoracostomy prompted investigation by computed transaxial tomography or ultrasound.

The operating time (132 ± 51 minutes) ranged from 95 to 190 minutes. The lungs were completely expanded immediately after empyema debridement. All patients were extubated at the completion of the procedure. There were no complications related to the operation. The chest tubes were removed 7 ± 1 days (range, 6 to 7 days) after thoracoscopy and discharge from hospital was on postoperative day 8 ± 1 (range, 7 to 8). None of the patients required further surgical intervention.

All patients have been clinically asymptomatic since discharge from hospital, and all wounds healed without infection. Plain chest radiographs are normal except for mild residual pleural thickening 2, 4, and 11 months after discharge (Fig 4). Each patient reports normal levels of activity.

View larger version (154K): [in this window] [in a new window]   Fig 4. . Plain radiograph 11 months after operation demonstrates mild residual pleural thickening (same patient as in Figure 2).

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

Cure in such adult patients has been described recently using intrapleural fibrinolytic therapy [6]. Seven patients were admitted for empyema alone. There were no treatment failures and patients were discharged from the hospital a mean of 9 days after the initiation of fibrinolytic therapy. A recent report of 5 children treated with intrapleural streptokinase noted complete resolution of loculated empyema in all patients [5]. In this latter series, chest tube removal was accomplished a mean of 6 days after initiation of fibrinolytic therapy. Hospital discharge, however, was a mean of 13 days after initiation of fibrinolytic therapy, considerably longer than in the present series.

Experience in adults [8, 9] and in children [10] has suggested that early prompt debridement of loculated empyema allows for a very high rate of cure and hastens an early discharge from hospital. In the present report, our experience with 3 pediatric patients supports this suggestion.

It is crucial that debridement of loculated empyema and decortication of chronic empyema be distinguished. Multiloculated fibrinopurulent empyema is amenable to adhesiolysis rendering a single cavity that can be appropriately drained without actual decortication. Formal decortication is reserved for patients in whom a fibrotic visceral peel has developed that restricts expansion of the underlying lung.

We advocate prompt diagnostic thoracentesis in all patients with parapneumonic effusion. The presence of overt empyema, or complicated parapneumonic effusion, mandates early closed tube thoracostomy. In the event that drainage proves inadequate as evidenced by persistent effusion, or if toxic signs persist, we propose that patients undergo diagnostic chest ultrasound or computed transaxial tomography if the diagnosis cannot be established by ultrasound. The presence of loculations is consistent with inadequate drainage and early intervention is indicated. Thoracoscopic and chemical debridement are both effective modes of therapy in selected children. Although thoracoscopic debridement seems to afford an earlier discharge from hospital, precise definition of cost effectiveness and long-term morbidity associated with these therapies will only be determined with further clinical experience.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Silen, Division of Pediatric Surgery, Department of Surgery, St. Louis University School of Medicine, 1465 South Grand Blvd, St. Louis, MO 63104.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Andrews NC, Parker EF, Shaw RR, Wilson NJ, Webb WR. Management of nontuberculous empyema: a statement of the subcommittee on surgery. Am Rev Respir Dis 1962;85:935–6.
2. Gustafson RA, Murray GF, Warden HE, Hill RC. Role of lung decortication in symptomatic empyemas in children. Ann Thorac Surg 1990;49:940–6.[Abstract]
3. Golladay ES, Wagner CW. Management of empyema in children. Am J Surg 1989;158:618–21.[Medline]
4. Hoff SJ, Neblett WW, Heller RM, et al. Postpneumonic empyema in childhood: selecting appropriate therapy. J Pediatr Surg 1989;24:659–63.[Medline]
5. Rosen H, Nadkarni V, Theroux M, Padman R, Klein J. Intrapleural streptokinase as adjunctive treatment for persistent empyema in pediatric patients. Chest 1993;103:1190–3.[Abstract/Free Full Text]
6. Robinson LA, Moulton AL, Fleming WH, Alonso A, Galbraith TA. Intrapleural fibrinolytic treatment of multiloculated thoracic empyemas. Ann Thorac Surg 1994;57:803–13.[Abstract]
7. Handman HP, Reuman PD. The use of urokinase for loculated thoracic empyema in children: a case report and review of the literature. Pediatr Infect Dis J 1993;12:958–9.[Medline]
8. Hutter JA, Harari D, Braimbridge MV. The management of empyema thoracis by thoracoscopy and irrigation. Ann Thorac Surg 1985;39:517–20.[Abstract]
9. Ridley PD, Braimbridge MV. Thoracoscopic debridement and pleural irrigation in the management of empyema thoracis. Ann Thorac Surg 1991;51:461–4.[Abstract]
10. Kern JA, Rodgers BM. Thoracoscopy in the management of empyema in children. J Pediatr Surg 1993;28:1128–32.[Medline]
11. Light RW. Parapneumonic effusions and empyema. Clin Chest Med 1985;6:55–62.[Medline]
12. Light RW. Management of parapneumonic effusions. Arch Intern Med 1981;141:1339–41.[Medline]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Silen, M. L. Articles by Weber, T. R. Search for Related Content PubMed PubMed Citation Articles by Silen, M. L. Articles by Weber, T. R.