title: Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial.
abstract: OBJECTIVE
  Management of empyema has been debated in the literature for decades. Although both primary video-assisted thoracoscopic surgery (VATS) and tube thoracostomy with pleural instillation of fibrinolytics have been shown to result in early resolution when compared to tube thoracostomy alone, there is a lack of comparative data between these modes of management. Therefore, we conducted a prospective, randomized trial comparing VATS to fibrinolytic therapy in children with empyema.
  
  
  METHODS
  After Institutional Review Board approval, children defined as having empyema by either loculation on imaging or more than 10,000 white blood cells/microL were treated with VATS or fibrinolysis. Based on our retrospective data using length of postoperative hospitalization as the primary end point, a sample size of 36 patients was calculated for an alpha of .5 and a power of 0.8. Fibrinolysis consisted of inserting a 12F chest tube followed by infusion of 4 mg tissue plasminogen activator mixed with 40 mL of normal saline at the time of tube placement followed by 2 subsequent doses 24 hours apart.
  
  
  RESULTS
  At diagnosis, there were no differences between groups in age, weight, degree of oxygen support, white blood cell count, or days of symptoms. The outcome data showed no difference in days of hospitalization after intervention, days of oxygen requirement, days until afebrile, or analgesic requirements. Video-assisted thoracoscopic surgery was associated with significantly higher charges. Three patients (16.6%) in the fibrinolysis group subsequently required VATS for definitive therapy. Two patients in the VATS group required ventilator support after therapy, one of whom required temporary dialysis. No patient in the fibrinolysis group clinically worsened after initiation of therapy.
  
  
  CONCLUSIONS
  There are no therapeutic or recovery advantages between VATS and fibrinolysis for the treatment of empyema; however, VATS resulted in significantly greater charges. Fibrinolysis may pose less risk of acute clinical deterioration and should be the first-line therapy for children with empyema.
authors.affiliation: Center for Prospective Clinical Trials, Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA. sspeter@cmh.edu
authors.forename: Shawn D
authors.initials: SD
authors.lastname: St Peter
authors.forename: Kuojen
authors.initials: K
authors.lastname: Tsao
authors.forename: Troy L
authors.initials: TL
authors.lastname: Spilde
authors.forename: Scott J
authors.initials: SJ
authors.lastname: Keckler
authors.forename: Christopher
authors.initials: C
authors.lastname: Harrison
authors.forename: Mary Ann
authors.initials: MA
authors.lastname: Jackson
authors.forename: Susan W
authors.initials: SW
authors.lastname: Sharp
authors.forename: Walter S
authors.initials: WS
authors.lastname: Andrews
authors.forename: Doug C
authors.initials: DC
authors.lastname: Rivard
authors.forename: Frank P
authors.initials: FP
authors.lastname: Morello
authors.forename: George W
authors.initials: GW
authors.lastname: Holcomb
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Ostlie
mesh_terms: D002675:Child, Preschool; D004653:Empyema / Q000188:drug therapy* / Q000382:microbiology / Q000601:surgery*; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D017722:Hospital Charges; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D011446:Prospective Studies; D012189:Retrospective Studies; D020775:Thoracic Surgery, Video-Assisted; D013907:Thoracostomy; D015912:Thrombolytic Therapy / Q000379:methods*; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator