N. A. Vaughan1, N. Spendlove2, L. S. Burkhalter1, A. L. Beres1,2, D. L. Diesen1,2 1Children’s Medical Center,Department Of Pediatric Surgery,Dallas, Tx, USA 2University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA
Introduction: Video-assisted thoracoscopic surgery (VATS) and fibrinolytics via tube thoracostomy (TT) have both been used as treatment for empyema in children. Early literature supported improved outcomes with early VATS, however, more recent data suggests equal efficacy with the exception of lower cost with fibrinolytic therapy. The addition of DNase to TPA has superior outcomes compared to either fibrinolytic alone or placebo in the adult literature. As our institute has transited from early VATS to fibrinolytic therapy with both TPA and DNase, we reviewed our experience with treatment of pediatric empyema.
Methods: We performed a retrospective review of patients less than 18 years old that underwent tube thoracostomy with administration of fibrinolytics or VATS between 2009 and 2014. T-test, one way ANOVA, and Chi squared were used to analyze the patient presentation, treatment, and outcomes. Statistical analysis was performed using GraphPad software, San Diego, CA.
Results: One-hundred and fifty-two patients were identified with 83 (55%) treated with VATS, 49 (32%) TT with TPA, and 20 (13%) TT with TPA/DNase. The VATS and fibrinolytic groups were similar in regards to age, weight, days of symptoms, oxygen support, WBC, and the number of visits prior to admission. There was no significant difference in days of oxygen support, narcotic utilization, fever, duration of TT, ICU stay, duration of intubation, or hospital length of stay. There was more utilization of sonography in the fibrinolytic group (1.3 vs 0.7, p=0.0001), but no difference in computed tomography. There was no significant difference in cost of hospitalization or readmission rate. Five patients (7%) required VATS for definitive therapy.
Conclusion: Both VATS and fibrinolytics are reasonable treatment options for pediatric empyema. There was a higher utilization of ultrasound with the fibrinolytic therapy without a significant effect on overall hospital cost. Our experience shows a conversion rate of 7% from fibrinolytic therapy to VATS that is lower than the reported literature. Further review and prospective study would be beneficial to elucidate differences for these findings.