Indian Pediatrics 2002; 39:957-961
Empyema thoracis is a problem frequently encountered in children. It can be either secondary to pneumonia, tuberculosis or post traumatic and the common organisms involved are Staphylococci, E. coli and anaerobes. Empyema encompasses a spectrum of inflammatory manifestations ranging from thin parapneumonic pleural effusion to the formation of a thick, constricting ring. The ideal definitive treatment of the suppurative process continues to be the early evacuation of loculated pus. Children with empyema who undergo incomplete drainage after tube thoracostomy are considered for surgical intervention(1). The earlier the intervention and debridement, the better are the results(2,3). Recently, thoracoscopy, popularly known as video assisted thoracoscopic surgery (VATS) has been introduced as a viable and potentially less morbid alternative to open thoracotomy. The authors report their experience of ten cases of empyema thoracis treated by thoraco-scopy over the past one and half year.
Subjects and Methods
We studied ten cases of empyema thoracis referred to us for intervention after failure of medical management from August 2000 to December 2001. All these patients were immunocompetent and had empyema secondary to pneumonia. All the children had received appropriate intravenous antibiotics. Two of these patients had been treated by tube thoracostomy and a diagnostic thoracocentesis was done in three.
All children underwent thoracoscopy under general endotracheal anesthesia with either single lung ventilation or high frequency low tidal volume dual lung ventilation with lung expansion synchronized with the movements of the surgeon. Carbon dioxide insufflation at 1 L/min and low pressure of 3-5 mm Hg was used as and when needed to facilitate exposure. After marking the site of the placement of the trocar, a diagnostic tap was done with a wide bore needle. Thereafter the trocar was placed in the mid axillary line. Additional one or two ports were then placed under direct vision so as to facilitate and accomplish debridement. We used five mm instruments in all the cases. As and when required conventional instruments such as forceps or curettes were introduced through the port sites for removing the fibrin clots and septae from the parietal and visceral surfaces. The fibrous peel was sent for histopathological examination and the pus or fluid was sent for culture. The lung was expanded and an intercostal drain was kept under thoracoscopic vision. The patients were monitored in the intensive care unit for six to twelve hours depending upon the severity of the illness. Immediate postoperative X-ray was taken for the ipsilateral and the contralateral chest. Antibiotics were administered for two weeks and the clinical course, body temperature, leucocyte count, and drainage of chest tube were recorded. The chest tube was removed after 2-5 days, or after it stopped draining and the column movement stopped. Adequate analgesia and chest physiotherapy was provided to prevent splinting and pulmonary complications. The children were followed up in the outpatient OPD after discharge. Chest radiographs were obtained in follow up after one month, and then after three months up to a period of six months after surgery. Antitubercular treatment was started in those patients who had a histopathological evidence of tuberculosis.
The patient details are provided in Table I. Of the ten patients, eight were in the fibrinopurulent phase and one in the organization phase. The last patient had symptoms of chronic cough and fever for more than one month, and was on treatment of a local doctor. The plain x-ray revealed multiple air filled pockets with a shifted mediastinum and basal collection. Lung tissue could not be very well appreciated on the plain X-ray. C.T. Scan of the chest revealed multiple air filled pockets occupying the entire left hemithorax with a basal collection with a very small amount of lung tissue seen. On thoracoscopy, the findings were confirmed and a left pneumonectomy was done due to irreversible inflammatory lesions and destroyed lung tissue. Blood transfusion was required only in this case. Two patients had multiple loculations on thoracoscopy. The posoperative chest tube drainage ranged from two to five days in the patients operated thoraco-scopically. We have not encountered any prolonged air leaks in any of the patients in our study. The patients were afebrile within 48 hours of the thoracoscopy. Analgesics were discontinued after 48-72 hours of the procedure. In only two patients was a definite microbiological diagnosis achieved. The organisms isolated included Streptococcus pneumoniae and Staphylococcus aureus. Two patients had a histopathological evidence of tuberculosis.
We have not encountered any relapse in our study. Two patients showed a small pneumothorax on the affected side in the postoperative period, which resolved spontaneously. All the children were well on follow up examination in the outpatient clinic with radiographs showing complete resolution. The average hospital stay was between seven to ten days. The follow up period was six months to one year.
TABLE I : Thoracoscopy in Management of Empyema Thoracis in Children
* Cases needed open Surgery, # Cases had ICD placed previously.
Recently, there is a worldwide increase in the number of loculated empyema resistant to conservative management(1,4). Our experience suggests the usefulness of thoracoscopic surgery in the management of empyema in children. American Thoracic Society has expanded on the definitions of empyema, identifying an early exudative phase, an intermediate phase and a late organizing phase(5). The fluid in the exudative phase is easily drainable. As the stage progress, there are formations of loculi in the fibrinopurulent phase, with lung parenchymal entrapment in the late organizing phase. An early surgical intervention is best performed before empyema reaches the organization stage(2,3).
The therapeutic aim is to remove all the infected material after removing the fibrous septae so as to restore the pleural cavity and facilitate lung expansion. Many modalities for management have been described, which include tube drainage, tube drainage with instillation of fibrinolytics, thoracotomy and open debridement and thoracoscopic debridement.
Tube thoracostomy or placement of an ICD is a blind procedure. There are chances of blockage of the tube by the thick pus or the fibrinopurulent peel or persistence of loculi. Inadequate drainage would on the other hand prolong recovery and hospitalization, lead to fibrosis and entrapment of the lung with restrictive lung disease and often ends with thoracotomy and decortications. Fibrinolytic therapy although reported as adjunctive therapy with tube thoracostomy, involves a prolonged hospital stay with high failure rate(6). This therapy would be of help only in patients with early disease(7). In the present study, neither of the two patients who had an intercostal drain placed previously were subjected to fibrinolytics.
Thoracoscopy in empyema has the following advantages(8-10):
(a) Accurate magnified assessment of lung parenchyma; (b) Precise staging of disease, unusual causes identified; (c) Mechanical breaking of all loculi – Complete evacuation; (d) Proper placement of chest drain under vision; (e) Marked reduction of bacterial load; (f) Minimal pulmonary dysfunction; (g) Reduced pain and hospital stay; (h) Reduced morbidity; (i) Better cosmesis.
Thoracotomy and open debridement is a major surgical undertaking. It disrupts the integrity of the chest wall and there are chances of increased blood loss requiring blood transfusion. There is more prolonged air leak when the peel is removed and may result in greater parenchymal loss(11). However, thoracotomy and open decortication is still the gold standard for patients who present late, and are in the organizing stage of empyema as would be seen on a CT scan. Thoracoscopy would not be useful in these cases and should be avoided.
With the recent advances in endoscopic and minimal invasive surgery, the approach to intrathoracic lesions in children has been dramatically altered. Thoracoscopy is a safe procedure for post-pneumonic empyema in young children, providing a rapid clinical and radiological recovery, relieving the children of unnecessary days of thoracostomy drainage and with a good cosmetic result.
The authors are grateful to Dr. M.H. Makwana, Superintendent & Director, K.M. School of Post Graduate Medicine & Research, V.S. Hospital, Ahmedabad for allowing us to publish the hospital data.
Contributors: All the authors were invovled in patient management and drafting of the manuscript. AVS will act as guarantor for the paper.
Competing interests: None stated.