A randomized trial of empyema therapy.
OBJECTIVE
To determine the optimal treatment of empyema thoracis (within the fibrinopurulent phase of illness) comparing pleural drainage and fibrinolytic therapy vs video-assisted thoracoscopic surgery (VATS), with regard to efficacy and duration of hospitalization.


METHODS
Twenty patients with confirmed parapneumonic empyema thoracis were randomized to chest tube pleural drainage plus streptokinase (CT-SK) vs VATS.


METHODS
University-based teaching hospital providing for Dallas County.


METHODS
Equivalent groups of patients with parapneumonic empyema thoracis were randomized to receive either of two therapies: CT-SK (n=9) or VATS (n=11). Outcomes analysis with respect to treatment efficacy, hospital duration, chest tube duration, hospital costs, and need for subsequent procedures was performed.


RESULTS
Each group suffered one mortality (p=not significant). When compared with the CT-SK group, the VATS group had a significantly higher primary treatment success [10/11, 91% vs 4/9, 44%; p<0.05 Fisher's Exact Test], lower chest tube duration (5.8+/-1.1 vs 9.8+/-1.3 days; p=0.03), and lower number of total hospital days (8.7+/-0.9 vs 12.8+/-1.1 days; p=0.009). Clinically relevant but not statistically significant differences in hospital costs ($16,642+/-2,841 vs $24,052+/-3,466, p=0.11) also favored the VATS group. Of note, all the CT-SK treatment failures could be salvaged with VATS, and none required thoracotomy.


CONCLUSIONS
In patients with loculated, complex fibrinopurulent parapneumonic empyema thoracis, a primary treatment strategy of VATS is associated with a higher efficacy, shorter hospital duration, and less cost than a treatment strategy that utilizes catheter-directed fibrinolytic therapy.
Wait
M A
MA
Division of Thoracic and Cardiovascular Surgery, Parkland Memorial Hospital, Dallas, TX 75235, USA. MWAIT@MEDNET.SWMED.EDU
Sharma
S
S
Hohn
J
J
Dal Nogare
A
A
D000328:Adult; D015505:Chest Tubes; D003131:Combined Modality Therapy; D004322:Drainage; D016724:Empyema, Pleural / Q000601:surgery*; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage; D006801:Humans; D008297:Male; D008875:Middle Aged; D013300:Streptokinase / Q000008:administration & dosage; D013906:Thoracoscopy; D016896:Treatment Outcome; D014741:Video Recording
D005343:Fibrinolytic Agents; D013300:Streptokinase