Pediatric empyema thoracis management: should the consensus be different for the developing countries?

• Published in: Journal of pediatric surgery Vol. 55; no. 3; pp. 513 - 517
• Main Authors: Shankar, Gowri, Sahadev, Ravindra, Santhanakrishnan, Ramesh
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.03.2020
• Subjects: Empyema thoracis stage II; Fibrinopurulent empyema; Intrapleural fibrinolysis; Randomized control study; Urokinase; Video-assisted thoracoscopic surgery; BTS; VATS; Randomized control study; USG; ICD; CT; PA; Urokinase; Video-assisted thoracoscopic surgery; IFT; Empyema thoracis stage II; Intrapleural fibrinolysis; ICU; CXR; Fibrinopurulent empyema
• ISSN: 0022-3468; 1531-5037; 1531-5037
• DOI: 10.1016/j.jpedsurg.2019.08.009

Despite the available consensus, intrapleural fibrinolytic therapy (IFT) in pediatric empyema is grossly underutilized in the Indian subcontinent where the disease burden is huge. Possible reasons may be epidemiological differences and physician bias. There is a paucity of literature from developing countries on the use of IFT in pediatric empyema thoracis. Hence, this study was undertaken to determine if fibrinolytic therapy is equivalent to video-assisted thoracoscopic surgery (VATS) in treating stage II empyema in children even in developing countries. Consecutive cases of stage II empyema were randomized to receive either IFT or VATS. The outcomes measured were the duration of hospital stay, efficacy of therapy, complications, and cost differences. 41 children were randomized to either VATS (n = 20) or IFT (n = 21) group. Overall successful clearance of empyema was achieved in 18 out of 20 (90%) children undergoing VATS and 20 out of 21(95.2%) children in fibrinolytic arm. The median length of the hospital stay was 7 and 8 days for VATS and IFT groups respectively (p = .24). Need for CT scan and blood transfusion was significantly higher in the VATS group than IFT group (p = .02 and .000). Fibrinolytic therapy is noninferior to VATS in the treatment of stage II empyema in children in the Indian subcontinent. A multicenter trial with larger sample size and uniform, detailed protocols on indications for CT scan, blood transfusions, nutrition status and costs involved will be needed to eliminate institutional bias and to increase the strength of the study. Randomized controlled study, treatment study and cost effectiveness study.