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Completed Prospective Studies Thoracoscopy versus Fibrinolysis in Children with Empyema

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 study.

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.

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