View Article PDF

Empyema in childhood causes significant morbidity and may be increasing in frequency.1,2 Empyema is classified into three stages: (1) An early exudative stage, (2) An intermediate fibrinopurulent stage, and (3) A late organising stage. The majority of cases present in the exudative stage and can be effectively managed with tube thoracostomy. Stage 3 empyema often requires open debridement of infective loculations to prevent lung restriction.The optimal management of fibrinopurulent empyema remains under debate. Two recent randomised controlled trials comparing fibrinolysis with video-assisted thoracoscopic surgery (VATS) in children have shown no significant difference in clinical outcome or length of postoperative hospital stay, but reduced treatment costs with fibrinolysis.3,4 Several series demonstrate that surgery can be safely avoided in approximately 80-90% of paediatric empyema patients with the use of fibrinolytics.1,3The British Thoracic Society recommends fibrinolysis as first line therapy for empyema.1 However, Bishay et al recently suggested that the failure rates for VATS can be considerably lower than for fibrinolysis if undertaken at a centre with high levels of thoracoscopic surgical experience.5VATS is minimally invasive and can be undertaken whilst the child is under general anaesthesia for the chest drain, thus allowing early and effective drainage.6-8Starship Children's Hospital (SSH) in Auckland, New Zealand, is a tertiary-referral centre for paediatric surgery. VATS was introduced in 2003 for the primary treatment of fibrinopurulent empyema. The aim of this study is to review the epidemiology, treatment and outcome of surgically-managed empyema in our first 5 years of VATS.Methods Study designA retrospective case-note review was undertaken of all surgically-managed empyemas at SSH over the 5 year period between 1 July 2003 and 30 June 2008. All children (<15 years) who had a diagnosis of empyema on hospital discharge coding data and had undergone surgical management were included in the study. Surgical intervention (VATS or thoracotomy) was determined from examination of the medical records. Patient demographics, mode of presentation, investigations, timing of illness onset to presentation, surgical intervention, and discharge, duration of chest drainage and complications were recorded. No cases were excluded. Statistical analysisDifferences between the ethnic distribution in our study and the New Zealand paediatric population were assessed using a goodness of fit test. Differences in surgical timing and chest drainage between those treated by VATS and thoracotomy were assessed using a Wilcoxon 2 sample test. Surgical techniqueSurgery was undertaken by three surgeons at SSH. The precise technique for VATS varied according to surgeon preference. Single lung ventilation with a bronchial blocker or double lumen tube was employed in a minority of cases but with increasing frequency later in the series. With the patient in the lateral position and the affected hemithorax uppermost, two or three 5 mm ports are placed and carbon dioxide pneumothorax established at 3-5 mmHg. Loculations are lysed, fibrinous peel removed and the thoracic cavity irrigated. One or two chest tubes are left in situ and removed on the ward when drainage minimal. Results Of 93 children with empyema 62, comprising the study population, were managed surgically (55 VATS, 7 thoracotomy) and 31 with tube thoracostomy alone. No children were managed with fibrinolysis. Of those treated by VATS, 45 (82%) underwent primary VATS and 10 (18%) underwent VATS following prior chest drain insertion. Demographics are listed in Table 1. Table 1. Patient characteristics Variables VATS* (N=55) Thoracotomy (N=7) Mean age in months (range) 38 (4-154) 57 (14-175) Gender, M:F 27:28 5:2 Ethnicity Pacific 2020 M ori NZ European Asian Other 23 16 6 8 2 5 0 2 0 0 *Video-assisted thoracoscopic surgery; 2020Mostly of Samoan, Tongan, Niuean, or Cook Islands origin. Children of Pacific and M ori ethnic origin were over-represented compared to their proportion of the New Zealand paediatric population, p<0.0001 (Figure 1). 9 Figure 1. Ethnic distribution of the study population and New Zealand paediatric population9 The Auckland 2006 Census showed a similar ethnic distribution: 14% Pacific Peoples, 11% M ori, 56% European, 19% Asian, 1% other. 10 Radiological investigations54 (87%) were investigated with ultrasonography (US) and 37 (60%) underwent chest computed tomography (CT). All children had either US or CT. Microbiology (Table 2)53 (85%) had a blood culture performed. Of these, 19 (36%) had a positive result. All 62 children had a pleural aspirate performed for culture. Of these 25 (40%) resulted in positive culture. Table 2. Microbiological isolates Isolates VATS Total (N=55) VATS Polynesian Population (N=39) Thoracotomy Total (N=7) Thoracotomy Polynesian Population (N=5) S. aureus 19 13 3 1 S. pneumonia 12 13 1 1 S. pyogenes 6 3 1 1 MRSA 2 2 0 0 Candida albicans 1 1 0 0 Serratia marcescens 1 0 0 0 No isolate 14 7 2 2 MRSA: methicillin-resistant Staphylococcus aureus. Clinical presentation (Table 3)24 (39%) of patients presented directly to SSH. 38 patients (61%) were transferred to SSH from another hospital; 36 patients from 13 hospitals across the North Island, 1 from the South Island and 1 from a Polynesian Island. Patients requiring a thoracotomy (43% of which were converted from VATS) had a significantly longer time from presentation at primary hospital to surgery than those treated with VATS (median 17 and 6 days respectively, p=0.007). 10 patients (16%) had intrapulmonary abscesses (7 were Polynesian) and 7 patients (11%) had multi-organ sepsis (5 were Polynesian). Table 3. Clinical presentation (expressed in median, range) Clinical presentation VATS Total (N=55) VATS Polynesian Population (N=39) Thoracotomy Total (N=7) Thoracotomy Polynesian Population (N=5) Aetiology: Pneumonia 55 39 6 4 Costal osteomyelitis 0 0 1 1 Symptom onset to presentation, days 5 (0-28) 5 (0-21) 4 (0-28) 4 (0-7) Initial presentation to surgery, days 6 (0-28) * 6 (0-28) 17 (3-43) * 17 (7-43) Interhospital transfer, N (%) 33 (60%) 25 (64%) 5 (71%) 3 (60%) Duration in primary hospital, days 2020 3 (0-21) 2 (0-21) 4 (1-23) 4 (1-23) Arrival at SSH to surgery, days 2020 2 (0-20) 3 (0-20) 7 (0-17) 9 (0-17) * p<0.01 2020For transferred patients. Outcome (Table 4)None of the patients who underwent VATS required a repeat procedure. 3 of those treated by thoracotomy initially underwent VATS but required conversion to an open procedure to allow adequate debridement of infective loculations (5% conversion to thoracotomy). Of those treated by VATS the chest drains remained in situ postoperatively for a median of 3 days. The total length of hospital stay was significantly longer in those who underwent thoracotomy (34 days) compared to VATS (19 days) (p=0.007). 10 children required PICU admission postoperatively and 1 preoperatively (8 of these were Polynesian). Table 4. Outcome (expressed in median, range) Outcome VATS Total (N=55) VATS Polynesian Population (N=39) Thoracotomy Total (N=7) Thoracotomy Polynesian Population (N=5) Surgery to chest drain removal, days 3 (1-11) 2020 3 (1-11) 2021 4 (2-7) 3 (2-6) Surgery to discharge, days 14 (2-43) 2021 13 (2-43) 2021 25 (9-76) 22 (9-76)

Summary

Abstract

Aim

The aim of this study was to review the epidemiology, treatment and outcome of surgically managed empyema in children.

Method

A retrospective review was undertaken of all surgically managed empyema at Starship Children's Hospital (Auckland, New Zealand) from 1 July 2003 to 30 June 2008.

Results

Of the 93 children diagnosed with empyema, 62 were managed surgically (55 VATS, 7 thoracotomy) and 31 with tube thoracostomy alone. 71% were of M ori or Pacific ethnicity despite making up just 30% of the New Zealand paediatric population (p

Conclusion

For the first time increased incidence of empyema in the Polynesian population has been documented. Severity of empyema may be higher within the Polynesian population affecting treatment outcome.

Author Information

Naomi J Wright, Senior House Officer; Philip Hammond, Clinical Fellow; Philip Morreau, Consultant; James Hamill, Consultant; Department of Paediatric Surgery, Starship Children 00b4s Hospital, Auckland

Acknowledgements

Thanks to Alistair Stewart for statistical advice, and the paediatric surgeons and respiratory paediatricians at SSH for facilitating this study.

Correspondence

Miss Naomi J. Wright, Department of Surgery, University College Hospital, London, NW1 2PG, United Kingdom

Correspondence Email

naomiwright@doctors.org.uk

Competing Interests

None.

Balfour-Lynn IM, Abrahamson E, Cohen G, et al. BTS guidelines for the management of pleural infection in children. Thorax. 2005;60(Suppl 1):i1-i21.Roxburgh CS, Youngson GG. Childhood empyema in North-East Scotland over the past 15 years. Scott Med J. 2007;52(4):25-7.Sonnappa S, Cohen G, Owens C, et al. Comparison of Urokinase and Video-assisted thoracoscopic surgery for treatment of childhood empyema. Am J Respir Crit Care Med. 2006;174:2.Peter S, Tsao K, Harrison C, et al. Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial. J Ped Surg. 2009;44(1):106-11.Bishay M, Short M, Shah K, et al. Efficacy of video-assisted thoracoscopic surgery in managing childhood empyema: a large single-centre study. J Ped Surg. 2009;44:337-42.Fuller MK, Helmrath MA. Thoracic empyema, application of video-assisted thoracic surgery and its current management. Curr Opin Pediatr. 2007;19(3):328-32.Coote N. Surgical versus non-surgical management of pleural empyema (Cochrane Review). The Cochrane Library 2004;1.Wait MA, Sharma S, Hohn J, et al. A randomized trial of empyema therapy. Chest. 1997;111:1548-51.Ministry of Youth Development. Summary demographics of children in New Zealand: 2006 Census. New Zealand.http://www.wyd.govt.nz (Accessed 03/08/09).Waitakere Government. 2006 Auckland Census Data. New Zealand. http://www.kaitakere.govt.nz (Accessed 14/03/11).Cohen G, Hjortdal V, Ricci M, et al. Primary thoracoscopic treatment of empyema in children. J Thorac Cardiovasc Surg. 2002;125(1):79-84.Grant C, Pati A, Tan D, et al. Ethnic comparisons of disease severity in children hospitalized with pneumonia in New Zealand. J Pediatr Child Health. 2001;37:32-7.Voss L, Lennon D, Okesene-Gafa K, et al. Invasive pneumococcal disease in a pediatric population, Auckland, New Zealand. Pediatr Infect Dis J. 1994;13:873-8.Hill PC, Wong CGS, Voss LM et al. Prospective study of 125 cases of Staphylococcal aureas bacteremia in children in New Zealand. Pediatr Infect Dis J. 2001;20:868-73.Grant CC, Scragg R, Tan D, et al. Hospitalisation for pneumonia in Auckland children. J Paediatr Child Health. 1998;34:355-9.Yee AMF, Hoang MP, Zaniga R et al. Association between FcRIIa-R131 allotype and bacteremic pneumococcal pneumonia. Clin Infect Dis. 2006;30:25-8.Roy S, Knox K, Sefal S, et al. MBL genotype and risk of invasive pneumococcal disease: a case control study. Lancet. 2002;359:1569-73.Rhoades ER. The major respiratory diseases of American Indians. Am Rev Respir Dis. 1990;141:595-600.Harris MF, Nolan B, Davidson A, et al. Early childhood pneumonia in Aborigines in Bourke, New South Wales. Med J Aust. 1984;140:705-7.Davidson M, Schraer CD, Parkinson AJ, et al. Invasive pneumococcal disease in an Alaskas native population, 1980 through 1986. JAMA. 1989;261:715-8.Christiansen J, Poulsen P, Ladefoged K, et al. Invasive pneumococcal disease in Greenland. Scand J Infect Dis. 2004;36:325-9.Chen J, Huang K, Chen Y, et al. Pediatric empyema: outcome analysis of thoracoscopic management. J Thorac Cardiovasc Surg. 2009;137(5):1195-9.

Contact diana@nzma.org.nz
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Empyema in childhood causes significant morbidity and may be increasing in frequency.1,2 Empyema is classified into three stages: (1) An early exudative stage, (2) An intermediate fibrinopurulent stage, and (3) A late organising stage. The majority of cases present in the exudative stage and can be effectively managed with tube thoracostomy. Stage 3 empyema often requires open debridement of infective loculations to prevent lung restriction.The optimal management of fibrinopurulent empyema remains under debate. Two recent randomised controlled trials comparing fibrinolysis with video-assisted thoracoscopic surgery (VATS) in children have shown no significant difference in clinical outcome or length of postoperative hospital stay, but reduced treatment costs with fibrinolysis.3,4 Several series demonstrate that surgery can be safely avoided in approximately 80-90% of paediatric empyema patients with the use of fibrinolytics.1,3The British Thoracic Society recommends fibrinolysis as first line therapy for empyema.1 However, Bishay et al recently suggested that the failure rates for VATS can be considerably lower than for fibrinolysis if undertaken at a centre with high levels of thoracoscopic surgical experience.5VATS is minimally invasive and can be undertaken whilst the child is under general anaesthesia for the chest drain, thus allowing early and effective drainage.6-8Starship Children's Hospital (SSH) in Auckland, New Zealand, is a tertiary-referral centre for paediatric surgery. VATS was introduced in 2003 for the primary treatment of fibrinopurulent empyema. The aim of this study is to review the epidemiology, treatment and outcome of surgically-managed empyema in our first 5 years of VATS.Methods Study designA retrospective case-note review was undertaken of all surgically-managed empyemas at SSH over the 5 year period between 1 July 2003 and 30 June 2008. All children (<15 years) who had a diagnosis of empyema on hospital discharge coding data and had undergone surgical management were included in the study. Surgical intervention (VATS or thoracotomy) was determined from examination of the medical records. Patient demographics, mode of presentation, investigations, timing of illness onset to presentation, surgical intervention, and discharge, duration of chest drainage and complications were recorded. No cases were excluded. Statistical analysisDifferences between the ethnic distribution in our study and the New Zealand paediatric population were assessed using a goodness of fit test. Differences in surgical timing and chest drainage between those treated by VATS and thoracotomy were assessed using a Wilcoxon 2 sample test. Surgical techniqueSurgery was undertaken by three surgeons at SSH. The precise technique for VATS varied according to surgeon preference. Single lung ventilation with a bronchial blocker or double lumen tube was employed in a minority of cases but with increasing frequency later in the series. With the patient in the lateral position and the affected hemithorax uppermost, two or three 5 mm ports are placed and carbon dioxide pneumothorax established at 3-5 mmHg. Loculations are lysed, fibrinous peel removed and the thoracic cavity irrigated. One or two chest tubes are left in situ and removed on the ward when drainage minimal. Results Of 93 children with empyema 62, comprising the study population, were managed surgically (55 VATS, 7 thoracotomy) and 31 with tube thoracostomy alone. No children were managed with fibrinolysis. Of those treated by VATS, 45 (82%) underwent primary VATS and 10 (18%) underwent VATS following prior chest drain insertion. Demographics are listed in Table 1. Table 1. Patient characteristics Variables VATS* (N=55) Thoracotomy (N=7) Mean age in months (range) 38 (4-154) 57 (14-175) Gender, M:F 27:28 5:2 Ethnicity Pacific 2020 M ori NZ European Asian Other 23 16 6 8 2 5 0 2 0 0 *Video-assisted thoracoscopic surgery; 2020Mostly of Samoan, Tongan, Niuean, or Cook Islands origin. Children of Pacific and M ori ethnic origin were over-represented compared to their proportion of the New Zealand paediatric population, p<0.0001 (Figure 1). 9 Figure 1. Ethnic distribution of the study population and New Zealand paediatric population9 The Auckland 2006 Census showed a similar ethnic distribution: 14% Pacific Peoples, 11% M ori, 56% European, 19% Asian, 1% other. 10 Radiological investigations54 (87%) were investigated with ultrasonography (US) and 37 (60%) underwent chest computed tomography (CT). All children had either US or CT. Microbiology (Table 2)53 (85%) had a blood culture performed. Of these, 19 (36%) had a positive result. All 62 children had a pleural aspirate performed for culture. Of these 25 (40%) resulted in positive culture. Table 2. Microbiological isolates Isolates VATS Total (N=55) VATS Polynesian Population (N=39) Thoracotomy Total (N=7) Thoracotomy Polynesian Population (N=5) S. aureus 19 13 3 1 S. pneumonia 12 13 1 1 S. pyogenes 6 3 1 1 MRSA 2 2 0 0 Candida albicans 1 1 0 0 Serratia marcescens 1 0 0 0 No isolate 14 7 2 2 MRSA: methicillin-resistant Staphylococcus aureus. Clinical presentation (Table 3)24 (39%) of patients presented directly to SSH. 38 patients (61%) were transferred to SSH from another hospital; 36 patients from 13 hospitals across the North Island, 1 from the South Island and 1 from a Polynesian Island. Patients requiring a thoracotomy (43% of which were converted from VATS) had a significantly longer time from presentation at primary hospital to surgery than those treated with VATS (median 17 and 6 days respectively, p=0.007). 10 patients (16%) had intrapulmonary abscesses (7 were Polynesian) and 7 patients (11%) had multi-organ sepsis (5 were Polynesian). Table 3. Clinical presentation (expressed in median, range) Clinical presentation VATS Total (N=55) VATS Polynesian Population (N=39) Thoracotomy Total (N=7) Thoracotomy Polynesian Population (N=5) Aetiology: Pneumonia 55 39 6 4 Costal osteomyelitis 0 0 1 1 Symptom onset to presentation, days 5 (0-28) 5 (0-21) 4 (0-28) 4 (0-7) Initial presentation to surgery, days 6 (0-28) * 6 (0-28) 17 (3-43) * 17 (7-43) Interhospital transfer, N (%) 33 (60%) 25 (64%) 5 (71%) 3 (60%) Duration in primary hospital, days 2020 3 (0-21) 2 (0-21) 4 (1-23) 4 (1-23) Arrival at SSH to surgery, days 2020 2 (0-20) 3 (0-20) 7 (0-17) 9 (0-17) * p<0.01 2020For transferred patients. Outcome (Table 4)None of the patients who underwent VATS required a repeat procedure. 3 of those treated by thoracotomy initially underwent VATS but required conversion to an open procedure to allow adequate debridement of infective loculations (5% conversion to thoracotomy). Of those treated by VATS the chest drains remained in situ postoperatively for a median of 3 days. The total length of hospital stay was significantly longer in those who underwent thoracotomy (34 days) compared to VATS (19 days) (p=0.007). 10 children required PICU admission postoperatively and 1 preoperatively (8 of these were Polynesian). Table 4. Outcome (expressed in median, range) Outcome VATS Total (N=55) VATS Polynesian Population (N=39) Thoracotomy Total (N=7) Thoracotomy Polynesian Population (N=5) Surgery to chest drain removal, days 3 (1-11) 2020 3 (1-11) 2021 4 (2-7) 3 (2-6) Surgery to discharge, days 14 (2-43) 2021 13 (2-43) 2021 25 (9-76) 22 (9-76)

Summary

Abstract

Aim

The aim of this study was to review the epidemiology, treatment and outcome of surgically managed empyema in children.

Method

A retrospective review was undertaken of all surgically managed empyema at Starship Children's Hospital (Auckland, New Zealand) from 1 July 2003 to 30 June 2008.

Results

Of the 93 children diagnosed with empyema, 62 were managed surgically (55 VATS, 7 thoracotomy) and 31 with tube thoracostomy alone. 71% were of M ori or Pacific ethnicity despite making up just 30% of the New Zealand paediatric population (p

Conclusion

For the first time increased incidence of empyema in the Polynesian population has been documented. Severity of empyema may be higher within the Polynesian population affecting treatment outcome.

Author Information

Naomi J Wright, Senior House Officer; Philip Hammond, Clinical Fellow; Philip Morreau, Consultant; James Hamill, Consultant; Department of Paediatric Surgery, Starship Children 00b4s Hospital, Auckland

Acknowledgements

Thanks to Alistair Stewart for statistical advice, and the paediatric surgeons and respiratory paediatricians at SSH for facilitating this study.

Correspondence

Miss Naomi J. Wright, Department of Surgery, University College Hospital, London, NW1 2PG, United Kingdom

Correspondence Email

naomiwright@doctors.org.uk

Competing Interests

None.

Balfour-Lynn IM, Abrahamson E, Cohen G, et al. BTS guidelines for the management of pleural infection in children. Thorax. 2005;60(Suppl 1):i1-i21.Roxburgh CS, Youngson GG. Childhood empyema in North-East Scotland over the past 15 years. Scott Med J. 2007;52(4):25-7.Sonnappa S, Cohen G, Owens C, et al. Comparison of Urokinase and Video-assisted thoracoscopic surgery for treatment of childhood empyema. Am J Respir Crit Care Med. 2006;174:2.Peter S, Tsao K, Harrison C, et al. Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial. J Ped Surg. 2009;44(1):106-11.Bishay M, Short M, Shah K, et al. Efficacy of video-assisted thoracoscopic surgery in managing childhood empyema: a large single-centre study. J Ped Surg. 2009;44:337-42.Fuller MK, Helmrath MA. Thoracic empyema, application of video-assisted thoracic surgery and its current management. Curr Opin Pediatr. 2007;19(3):328-32.Coote N. Surgical versus non-surgical management of pleural empyema (Cochrane Review). The Cochrane Library 2004;1.Wait MA, Sharma S, Hohn J, et al. A randomized trial of empyema therapy. Chest. 1997;111:1548-51.Ministry of Youth Development. Summary demographics of children in New Zealand: 2006 Census. New Zealand.http://www.wyd.govt.nz (Accessed 03/08/09).Waitakere Government. 2006 Auckland Census Data. New Zealand. http://www.kaitakere.govt.nz (Accessed 14/03/11).Cohen G, Hjortdal V, Ricci M, et al. Primary thoracoscopic treatment of empyema in children. J Thorac Cardiovasc Surg. 2002;125(1):79-84.Grant C, Pati A, Tan D, et al. Ethnic comparisons of disease severity in children hospitalized with pneumonia in New Zealand. J Pediatr Child Health. 2001;37:32-7.Voss L, Lennon D, Okesene-Gafa K, et al. Invasive pneumococcal disease in a pediatric population, Auckland, New Zealand. Pediatr Infect Dis J. 1994;13:873-8.Hill PC, Wong CGS, Voss LM et al. Prospective study of 125 cases of Staphylococcal aureas bacteremia in children in New Zealand. Pediatr Infect Dis J. 2001;20:868-73.Grant CC, Scragg R, Tan D, et al. Hospitalisation for pneumonia in Auckland children. J Paediatr Child Health. 1998;34:355-9.Yee AMF, Hoang MP, Zaniga R et al. Association between FcRIIa-R131 allotype and bacteremic pneumococcal pneumonia. Clin Infect Dis. 2006;30:25-8.Roy S, Knox K, Sefal S, et al. MBL genotype and risk of invasive pneumococcal disease: a case control study. Lancet. 2002;359:1569-73.Rhoades ER. The major respiratory diseases of American Indians. Am Rev Respir Dis. 1990;141:595-600.Harris MF, Nolan B, Davidson A, et al. Early childhood pneumonia in Aborigines in Bourke, New South Wales. Med J Aust. 1984;140:705-7.Davidson M, Schraer CD, Parkinson AJ, et al. Invasive pneumococcal disease in an Alaskas native population, 1980 through 1986. JAMA. 1989;261:715-8.Christiansen J, Poulsen P, Ladefoged K, et al. Invasive pneumococcal disease in Greenland. Scand J Infect Dis. 2004;36:325-9.Chen J, Huang K, Chen Y, et al. Pediatric empyema: outcome analysis of thoracoscopic management. J Thorac Cardiovasc Surg. 2009;137(5):1195-9.

Contact diana@nzma.org.nz
for the PDF of this article

View Article PDF

Empyema in childhood causes significant morbidity and may be increasing in frequency.1,2 Empyema is classified into three stages: (1) An early exudative stage, (2) An intermediate fibrinopurulent stage, and (3) A late organising stage. The majority of cases present in the exudative stage and can be effectively managed with tube thoracostomy. Stage 3 empyema often requires open debridement of infective loculations to prevent lung restriction.The optimal management of fibrinopurulent empyema remains under debate. Two recent randomised controlled trials comparing fibrinolysis with video-assisted thoracoscopic surgery (VATS) in children have shown no significant difference in clinical outcome or length of postoperative hospital stay, but reduced treatment costs with fibrinolysis.3,4 Several series demonstrate that surgery can be safely avoided in approximately 80-90% of paediatric empyema patients with the use of fibrinolytics.1,3The British Thoracic Society recommends fibrinolysis as first line therapy for empyema.1 However, Bishay et al recently suggested that the failure rates for VATS can be considerably lower than for fibrinolysis if undertaken at a centre with high levels of thoracoscopic surgical experience.5VATS is minimally invasive and can be undertaken whilst the child is under general anaesthesia for the chest drain, thus allowing early and effective drainage.6-8Starship Children's Hospital (SSH) in Auckland, New Zealand, is a tertiary-referral centre for paediatric surgery. VATS was introduced in 2003 for the primary treatment of fibrinopurulent empyema. The aim of this study is to review the epidemiology, treatment and outcome of surgically-managed empyema in our first 5 years of VATS.Methods Study designA retrospective case-note review was undertaken of all surgically-managed empyemas at SSH over the 5 year period between 1 July 2003 and 30 June 2008. All children (<15 years) who had a diagnosis of empyema on hospital discharge coding data and had undergone surgical management were included in the study. Surgical intervention (VATS or thoracotomy) was determined from examination of the medical records. Patient demographics, mode of presentation, investigations, timing of illness onset to presentation, surgical intervention, and discharge, duration of chest drainage and complications were recorded. No cases were excluded. Statistical analysisDifferences between the ethnic distribution in our study and the New Zealand paediatric population were assessed using a goodness of fit test. Differences in surgical timing and chest drainage between those treated by VATS and thoracotomy were assessed using a Wilcoxon 2 sample test. Surgical techniqueSurgery was undertaken by three surgeons at SSH. The precise technique for VATS varied according to surgeon preference. Single lung ventilation with a bronchial blocker or double lumen tube was employed in a minority of cases but with increasing frequency later in the series. With the patient in the lateral position and the affected hemithorax uppermost, two or three 5 mm ports are placed and carbon dioxide pneumothorax established at 3-5 mmHg. Loculations are lysed, fibrinous peel removed and the thoracic cavity irrigated. One or two chest tubes are left in situ and removed on the ward when drainage minimal. Results Of 93 children with empyema 62, comprising the study population, were managed surgically (55 VATS, 7 thoracotomy) and 31 with tube thoracostomy alone. No children were managed with fibrinolysis. Of those treated by VATS, 45 (82%) underwent primary VATS and 10 (18%) underwent VATS following prior chest drain insertion. Demographics are listed in Table 1. Table 1. Patient characteristics Variables VATS* (N=55) Thoracotomy (N=7) Mean age in months (range) 38 (4-154) 57 (14-175) Gender, M:F 27:28 5:2 Ethnicity Pacific 2020 M ori NZ European Asian Other 23 16 6 8 2 5 0 2 0 0 *Video-assisted thoracoscopic surgery; 2020Mostly of Samoan, Tongan, Niuean, or Cook Islands origin. Children of Pacific and M ori ethnic origin were over-represented compared to their proportion of the New Zealand paediatric population, p<0.0001 (Figure 1). 9 Figure 1. Ethnic distribution of the study population and New Zealand paediatric population9 The Auckland 2006 Census showed a similar ethnic distribution: 14% Pacific Peoples, 11% M ori, 56% European, 19% Asian, 1% other. 10 Radiological investigations54 (87%) were investigated with ultrasonography (US) and 37 (60%) underwent chest computed tomography (CT). All children had either US or CT. Microbiology (Table 2)53 (85%) had a blood culture performed. Of these, 19 (36%) had a positive result. All 62 children had a pleural aspirate performed for culture. Of these 25 (40%) resulted in positive culture. Table 2. Microbiological isolates Isolates VATS Total (N=55) VATS Polynesian Population (N=39) Thoracotomy Total (N=7) Thoracotomy Polynesian Population (N=5) S. aureus 19 13 3 1 S. pneumonia 12 13 1 1 S. pyogenes 6 3 1 1 MRSA 2 2 0 0 Candida albicans 1 1 0 0 Serratia marcescens 1 0 0 0 No isolate 14 7 2 2 MRSA: methicillin-resistant Staphylococcus aureus. Clinical presentation (Table 3)24 (39%) of patients presented directly to SSH. 38 patients (61%) were transferred to SSH from another hospital; 36 patients from 13 hospitals across the North Island, 1 from the South Island and 1 from a Polynesian Island. Patients requiring a thoracotomy (43% of which were converted from VATS) had a significantly longer time from presentation at primary hospital to surgery than those treated with VATS (median 17 and 6 days respectively, p=0.007). 10 patients (16%) had intrapulmonary abscesses (7 were Polynesian) and 7 patients (11%) had multi-organ sepsis (5 were Polynesian). Table 3. Clinical presentation (expressed in median, range) Clinical presentation VATS Total (N=55) VATS Polynesian Population (N=39) Thoracotomy Total (N=7) Thoracotomy Polynesian Population (N=5) Aetiology: Pneumonia 55 39 6 4 Costal osteomyelitis 0 0 1 1 Symptom onset to presentation, days 5 (0-28) 5 (0-21) 4 (0-28) 4 (0-7) Initial presentation to surgery, days 6 (0-28) * 6 (0-28) 17 (3-43) * 17 (7-43) Interhospital transfer, N (%) 33 (60%) 25 (64%) 5 (71%) 3 (60%) Duration in primary hospital, days 2020 3 (0-21) 2 (0-21) 4 (1-23) 4 (1-23) Arrival at SSH to surgery, days 2020 2 (0-20) 3 (0-20) 7 (0-17) 9 (0-17) * p<0.01 2020For transferred patients. Outcome (Table 4)None of the patients who underwent VATS required a repeat procedure. 3 of those treated by thoracotomy initially underwent VATS but required conversion to an open procedure to allow adequate debridement of infective loculations (5% conversion to thoracotomy). Of those treated by VATS the chest drains remained in situ postoperatively for a median of 3 days. The total length of hospital stay was significantly longer in those who underwent thoracotomy (34 days) compared to VATS (19 days) (p=0.007). 10 children required PICU admission postoperatively and 1 preoperatively (8 of these were Polynesian). Table 4. Outcome (expressed in median, range) Outcome VATS Total (N=55) VATS Polynesian Population (N=39) Thoracotomy Total (N=7) Thoracotomy Polynesian Population (N=5) Surgery to chest drain removal, days 3 (1-11) 2020 3 (1-11) 2021 4 (2-7) 3 (2-6) Surgery to discharge, days 14 (2-43) 2021 13 (2-43) 2021 25 (9-76) 22 (9-76)

Summary

Abstract

Aim

The aim of this study was to review the epidemiology, treatment and outcome of surgically managed empyema in children.

Method

A retrospective review was undertaken of all surgically managed empyema at Starship Children's Hospital (Auckland, New Zealand) from 1 July 2003 to 30 June 2008.

Results

Of the 93 children diagnosed with empyema, 62 were managed surgically (55 VATS, 7 thoracotomy) and 31 with tube thoracostomy alone. 71% were of M ori or Pacific ethnicity despite making up just 30% of the New Zealand paediatric population (p

Conclusion

For the first time increased incidence of empyema in the Polynesian population has been documented. Severity of empyema may be higher within the Polynesian population affecting treatment outcome.

Author Information

Naomi J Wright, Senior House Officer; Philip Hammond, Clinical Fellow; Philip Morreau, Consultant; James Hamill, Consultant; Department of Paediatric Surgery, Starship Children 00b4s Hospital, Auckland

Acknowledgements

Thanks to Alistair Stewart for statistical advice, and the paediatric surgeons and respiratory paediatricians at SSH for facilitating this study.

Correspondence

Miss Naomi J. Wright, Department of Surgery, University College Hospital, London, NW1 2PG, United Kingdom

Correspondence Email

naomiwright@doctors.org.uk

Competing Interests

None.

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