Management of multiloculated empyema thoracis in children: thoracotomy versus fibrinolytic treatment.
OBJECTIVE
Progression of empyema, with the development of fibrinous adhesions and loculations, makes simple drainage difficult or impossible. The appropriate management remains controversial. Intrapleural fibrinolytic treatment to facilitate drainage of loculated empyema instead of open thoracotomy has been advocated recently. The aim of this study was to evaluate the effectiveness of the intrapleural fibrinolytic application.


METHODS
In our clinic we used urokinase in 28 patients and performed thoracotomy and decortication in another 43. The two groups of patients had similar characteristics. Mean age was 10.2 (range: 3-14 years). All had undergone medical treatment and tube thoracostomy. Empyema severity score (ESS) was measured in all.


RESULTS
Fibrinolytic treatment, and thoracotomy and decortication had complete response rates of 67.8 and 100%, respectively. Treatment was ineffective in six (21.4%) out of 28 patients who underwent urokinase instillation; they recovered after thoracotomy. In three (10.7%) patients, partial resolution was observed. One patient died of sepsis and pleural hemorrhage. Mean hospital stay after urokinase was 10.7 (range: 6-17) days. In the thoracotomy group, all patients recovered completely. No deaths occurred. Postoperative complications were incisional infection in two patients, atelectasis in one and reoperation after hemorrhage in one. Mean hospital stay after surgery was 9.5 (5-19) days. The ESS of cases operated on was lower postoperatively (0.3 versus 0.8).


CONCLUSIONS
Continued conservative therapy risks morbidity and mortality. Thoracotomy-decortication can be used successfully and must remain the preferred method in the treatment of multiloculated pediatric empyema.
Balci
Akin Eraslan
AE
Department of Thoracic & Cardiovascular Surgery, Dicle University School of Medicine, Diyarbakir, Turkey. abalci@dicle.edu.tr
Eren
Sevval
S
Ulkü
Refik
R
Eren
Mehmet Nesimi
MN
D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D016724:Empyema, Pleural / Q000188:drug therapy* / Q000601:surgery*; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D011446:Prospective Studies; D018709:Statistics, Nonparametric; D013908:Thoracotomy; D015912:Thrombolytic Therapy; D016896:Treatment Outcome; D014568:Urokinase-Type Plasminogen Activator / Q000627:therapeutic use*
D005343:Fibrinolytic Agents; D014568:Urokinase-Type Plasminogen Activator