ORIGINAL ARTICLE

Decortication in paediatric empyema, comparative studyof early vs late intervention

Vivek Gandotra & Arvind Kohli & Gurjit Singh

Received: 23 June 2012 /Revised: 4 October 2012 /Accepted: 5 April 2013 /Published online: 9 May 2013# Indian Association of Cardiovascular-Thoracic Surgeons 2013

AbstractBackground A retrospective study was conducted at GovtMedical College, Jammu in the pediatric patients who werereferred to Cardio Thoracic and Vascular Surgery depart-ment with thoracic empyema and were taken up for thora-cotomy and decortication Our experience showed that earlyintervention gave better results than in group with delayedintervention.Material and methods Between January 2003 and 2011, 76patients underwent pleural decortication in pediatric agegroup presenting with thoracic empyema who did not re-spond to conservative management. 45 patients were maleand 31 patients were female. They were initially evaluatedwith routine chest radio graphs and with Computed Tomog-raphy (CT) chest. Diagnosis of thoracic empyema was madein these cases with radio graphic evidence and was substan-tiated with pleural fluid cultures 62 underwent early inter-vention whereas 14 had delayed intervention.Results 62 (84 %) patients underwent early decortication(within 4 weeks of Intercostaltube insertion) whereas 14(16 %) cases were taken up for delayed decortication be-yond 1 month due to unavoidable reasons like delayedreferral, high grade fever or because of other co morbiddiseases. In early group all patients responded well to earlydecortications. 6 (10 %) patients required secondary inter-vention that included 4 (6.4 %) patients due to recurrence ofempyema or lung collapse after surgery & 2(3.2 %) patientsrequired lung resection. and the mean hospital stay was12 days In late intervention group, it was found that theoperative time increased, the duration of chest drain alsoincreased due to air leak/increased drainage leading to

increased hospital stay (16 days) and 6 (42 %) patientsrequired secondary intervention.Conclusion Early decortication is an effective surgicaltreatment for thoracic empyema as It facilitates earlyevacuation and mechanical decortication of pleuralspace with no additional morbidity and leads to reducedtime for chest tube drainage and shortens hospital stay.

Keywords Decortication . Empyema . Pediatric

Introduction

Thoracic Empyema is a collection of purulent material in thepleural space which occurs when bacteria in pleural fluidcreated products of infection that prevent full expansion ofthe lung. It progresses through three phases Phase one is anexudative phase with thin fluid and few cells, the secondphase is fibrinopurulent phase with large quantities of Whiteblood cells and Fibrin, resulting in loculation and a liningmembrane formed around lung. The third phase is an orga-nizing phase with firbroblast growing into the exudate re-ducing an inelastic membranous peel that encases the lung[1]. Pediatric empyema is associated with considerable mor-bidity. The optimal management is controversial with treat-ment options ranging from antibiotics alone or in combinationof chest tube thoracosotomy with or without fibrinolyticagents, Thoracoscopy or thoracotomy with decortications[2]. Surgical management of empyema thoracis is reservedfor the patients who do not respond to conservative manage-ment and chest tube drainage.

Patients and methods

Between January 2003 and January 2011 patients of thoracicempyema in pediatric hospital not responding to medical

V. Gandotra :A. Kohli (*) :G. SinghDepartment of Cardiothoracic and Vascular Surgery,Govt Medical College, 39B/D Gandhi Nagar,Jammu, J&K 180004, Indiae-mail: Kohli_arvind@yahoo.com

Indian J Thorac Cardiovasc Surg (April–June 2013) 29(2):110–113DOI 10.1007/s12055-013-0209-1

management and chest tube thoracosotomy were included inthis study Parapneumonic effusion was the most frequentaetiology for empyema.

A total of Seventy six (76) patients were refered toCardio Thoracic and Vascular Surgery department for sur-gical management with forty five (45) males and thirty one(31) female patients (Table 1). Diagnosis of thoracic empy-ema was made in these cases with radio graphic evidencechest skiagrams and Contrast Enhanced Computed Tomog-raphy (CECT) (Fig. 1) 62 (84 %) patients underwent earlydecortications (within 4 weeks of InterCostalTube insertion)whereas14 (16 %) were such which were taken up fordelayed decortication beyond 1 month due to unavoidablereasons like delayed referral to OPD/ward by pediatrician,high grade fever or because of other comorbid diseases. Inthese cases we found that hospital stay increased, operativetime increased, duration of chest placement increased due toair leak/increased drainage (Table 2).

Results

Right lung was involved more than left in early group andvice versa in delayed group (Table 3).

Patients presented with various signs and symptomsof thoracic empyema as depicted in (Table 4) 62/76patients referred to us were taken up for early decorti-cation as the conservative management had failed(Fig. 2). Average operative time was 84 min±20 min.Duration of chest tube placement in post operative periodwas 3–10 days (4.2 days mean) (Fig. 3). There was notmuch difference in post operative recovery betweenpatients of different age group and both sexes. Howeverin delayed intervention group of 14 patients operativetime was 106±20 min, duration of chest tube placementwas 8–24 days (mean of 11 days). Many patients requiredsecondary intervention in form of reoperation or vaccumassisted suction (Table 5).

Discussion

Lower respiratory tract infections in children were compli-cated by parapneumonic fluid collections in fifty to ninetyfour cases but this usually resolves spontaneously afterpneumonia. One in every one hundred and fifty five casesof pneumonia progresses to established empyema accordingto the report of Chonmaitree et al. [3]. Thoracic empyema isa common problem in pediatric age group since the clinicalentity empyema was first described it’s treatment has beendebated. All though chest tube thorocostomy is effective intreatment of early empyema, 16 to 18 % of children do notrespond to close drainage. Most children do not present

Table 1 Age group

Age Early group Late groupNo. of patients with (%) No of patients with (%)

0 to 4 years 24 (38.7 %) 2 [14.3 %]

5 to 8 years 25 (40.3 %) 8 [57.1 %]

9 to 12 years 7 (11.2 %) 4 (29 %)

12 to 14 years 6 (9.8 %) Nil

Fig. 1 Left pleural empyema with pleural intercostal drain

Table 2 Patients demography

Legend Early group Late group

Age group 4 months –14 years

3 year –12 year

Mean age 4.4 years 6.2 year

Sex ratio 36:26 (1.38:1) 9;5

Duration of hospital stay 12.1+−4.6 days 16.8+−6.2 day

Duration of chest tubeplacement

7+−3.2 days 13+−6.4 days

CT Scan 51 14

Complication (Reoperated) 04 06

Table 3 Lung involvement

Site Early group Late groupNo. of patients with (%) No of patients with (%)

Bilateral Nil Nil–

Right 38 (61.3) 04 (28.58)

Left 24 (38.7) 10 (74.421)

Indian J Thorac Cardiovasc Surg (April–June 2013) 29(2):110–113 111

during 24 to 72 h of empyema development, when pleuralfluid is thin and can be easily drained. The majority haveprogressed to the fibrino purulent stage of empyema whenthick fluid and loculation render even large bore chest tubeineffective. A meta-analysis reviewed the differences be-tween primary operative treatment with nonoperative man-agement and revealed striking reductions in length of stay,duration of tube thoracostomy, and duration of antibiotics[4]. The results from metaanalysis suggest that primaryoperative therapy is associated with a lower in-hospitalmortality rate, reintervention rate, length of stay, time withtube thoracostomy, and time of antibiotic therapy, comparedwith nonoperative treatment.

In our series all these 62 patients were successfullymanaged with early decortication. Only four patientsrequired resurgery due to recurrence of empyema andnon expansion of lung due to bronchopleural fistula. Wehad encouraging results in all the patients and there wasno mortality in our series.

Early in the series we recognized that loculation with peelover lung restricts the lung expansions in all cases. Earlydecortication had been the right management in all cases andhelped in early recovery, lesser chest tube duration, lesserhospital stay and less duration of antibiotics. We did notperform any video assisted thoracoscopic decortication. Wefeel more comfortable with open techniques as in manypatients there were tight adhesions on mediastinal, hilar ordiaphragmatic surfaces. An objection to early decorticationin parapneunomic empyema based on the fact that lungparenchyma damage is more and therefore increased riskof bronchopleural fistula and anesthestic complications [5]In our present study we experienced no such problems inpaediatric patient who underwent early decortication. Ratherearly decortication suffices as a fool proof treatment forempyema thoracic in paediatric age group.

Kosloske et al. [6] established in their study that decor-tication procedures have a low risk and are effective in

Table 4 Clinical signs and symptoms in 76 patients of empyemathoracis

Fever 76 (100 %)

Cough 70 (90.3 %)

Decreased breath sounds 74 (96.7 %)

Dysponea 40 (42.9 %)

Chest pain 32 (29 %)

Rales 36 (35.4 %)

Ronchi 30 (17 %)

Fig. 2 Operative picture of patient undergoing early decortication

Fig. 3 Post operative Xray after early decortication

Table 5 Observations & results

Legend Early intervention Delayed

Operative time (Minutes) 84+−20 106+−20

Duration of chest tubeplacement

4.2 (3 to 10 days) 7.5 (6 to 21 days)

Length of hospital stay(Preoperative evaluationto discharge)

8.3 (7 to 16 days) 11 (8 to 24 days)

Post operative antibiotic 16.3 (10 to28 days) 17 (10 to30 days)

Additional surgical procedure(redo decortications/lobectemy)

4 cases (2 cases oflobectemy)

6/14

Vaccum assisted suction 6/62 8/14

112 Indian J Thorac Cardiovasc Surg (April–June 2013) 29(2):110–113

children with empyema. They should be considered asdefinitive therapy, rather than as a last resort.

In all patients, the decision of the operation was made withcomputerized tomography by showing the nature, quantity andlocation of the fluid and the amount of pleural thickening.Moreover CT scan demonstrates the degree of lung trapment.Our previous experience suggested that the children, whosuffer from unresolved empyema for long duration, mightrecover by early decortication. Therefore, after 10 days ofantibiotic treatment and tube drainage, if the clinical course isunimproved and thoracic space shows a restricted lung owingto persistant collection and thickened pleura on CT scan, thedecision for operation were made. In our series, postoperativelyhospital stay ranged from 5 to 8 days and this result is quitereasonable when compared with the published literature [7, 8].

Empyema results in significant morbidity to the patientand health care cost to the family and payers. Currenttreatment of empyema in children is highly variable andthere are numerous surgical options suggesting no singularapproach is uniformly effective [9]. We believe that earlydecortication is a safe, curative and cost effective treatmentin childhood empyema thoracis with low morbidity.

Acknowledgments Dr Rekha Harish, Dr Noor Ali, Dr Mohit Arora,Dr Puja Vimesh

Conflicts of interests Nil

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