Thoracoscopic Decortication vs Tube
Thoracostomy with Fibrinolysis for Empyema in Children: A
Prospective, Randomized Trial (Shawn D. St. Peter, Kuojen Tsao,
Christopher Harrison, Mary Ann Jackson,Troy L. Spilde, Scott J.
Keckler, Susan W. Sharp, Walter S. Andrews, George W. Holcomb III,
Daniel J. Ostlie) Journal of Pediatric Surgery 2008;44:106-111.
This was a single institution, prospective, randomized clinical
trial involving patients who are found to have one or more
septations within a pleural effusion as diagnosed by ultrasound or
computed tomography. Additionally, patients with a pleural effusion
wherein a pleural tap reveals pus, as defined by many
(>10,000/mm3 ) white blood cells or positive
cultures, will be considered. This is intended to be a definitive
Based on our retrospective data using length of postoperative
hospitalization, a sample size of 36 patients was calculated with
an alpha of 0.5 and a power of 0.8. Video-assisted thoracoscopic
debridement (VATS) were performed in standard fashion with chest
tube left behind after the operation. Fibrinolysis consisted of
inserting a 12 Fr chest tube followed by infusion of 4mg tPA mixed
in 40 ml of normal saline at the time of tube placement followed
by two subsequent doses 24 hours apart.
At diagnosis, there were no differences between groups in age,
weight, degree of oxygen support, WBC count or days of symptoms.
Outcomes showed no difference in length of hospitalization, days of
oxygen support, days with a fever or number of analgesic doses.
The procedure charges were significantly higher in the VATS
group. Three patients (16.6%) in the fibrinolysis arm required VATS
for definitive therapy. Two patients in the VATS group required
ventilator support after therapy, one of which required temporary
dialysis. No patients in the fibrinolysis group clinically worsened
after initiation of therapy.
Conclusions: There are no therapeutic or
recovery advantages between VATS and fibrinolysis for the treatment
of empyema. However, VATS resulted in significantly greater
charges. Fibrinolysis should be considered the first line therapy
for children with empyema.