title: Management of late-stage parapneumonic empyema.
abstract: OBJECTIVE
  Despite the reported value of early video-assisted thoracoscopic surgery (VATS) for empyema, many children are still referred to the surgeon late in the disease process. The authors wished to determine the optimal management strategy for this group of children.
  
  
  METHODS
  Medical records of all children (n = 70) from 1990 to 2000 with late-presenting empyema (stage II or III) were reviewed. Patients were grouped as (G1) successful management with chest tube (CT), (G2) surgery after initial CT, (G3) thoracentesis followed by surgery, and (G4) surgery alone.
  
  
  RESULTS
  There were no significant differences with respect to age, gender, pleural cultures or fluid analysis. Fifty-one (73%) patients required surgical intervention. Treatment using CT (G1, G2) or thoracentesis (G3) was associated with prolonged length of stay (LOS) when compared with surgery alone (G4; 12 v 8 days). For G2, G3, and G4, rapid clinical improvement and early discharge (6 days) was seen after surgery. For all surgery groups (G2, G3, G4), video-assisted thoracoscopic surgery (n = 19) was associated with a longer postoperative fever (4 v 2 days; P <.05), but a shorter total LOS (12 v 15 days; P <.05) when compared with open decortication (n = 32).
  
  
  CONCLUSIONS
  Over 70% of children with late presenting empyema required surgery, including more than half of the children who received initial chest tube drainage. Delay in surgery was associated with more procedures, more radiographs, and an increased LOS. Despite later intervention, patients undergoing surgery as an initial approach had the shortest length of stay. Early surgical intervention is indicated for most children referred with established empyema.
authors.affiliation: Washington University School of Medicine & St Louis Children's Hospital, St Louis, MO, USA.
authors.forename: Li Ern
authors.initials: LE
authors.lastname: Chen
authors.forename: Jacob C
authors.initials: JC
authors.lastname: Langer
authors.forename: Patrick A
authors.initials: PA
authors.lastname: Dillon
authors.forename: Robert P
authors.initials: RP
authors.lastname: Foglia
authors.forename: Charles B
authors.initials: CB
authors.lastname: Huddleston
authors.forename: Eric N
authors.initials: EN
authors.lastname: Mendeloff
authors.forename: Robert K
authors.initials: RK
authors.lastname: Minkes
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D016724:Empyema, Pleural / Q000188:drug therapy / Q000601:surgery*; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D011008:Pneumococcal Infections / Q000601:surgery; D018410:Pneumonia, Bacterial / Q000188:drug therapy / Q000601:surgery*; D012086:Reoperation / Q000379:methods; D012189:Retrospective Studies; D013203:Staphylococcal Infections / Q000601:surgery; D013211:Staphylococcus aureus / Q000302:isolation & purification; D013296:Streptococcus pneumoniae / Q000302:isolation & purification; D020775:Thoracic Surgery, Video-Assisted / Q000379:methods; D013908:Thoracotomy / Q000379:methods; D015912:Thrombolytic Therapy / Q000379:methods