Experience with video-assisted thoracoscopic surgery in the management of complicated pneumonia in children

doi:10.1053/jpsu.2001.20705

Journal of Pediatric Surgery

Volume 36, Issue 2, February 2001, Pages 316-319

Presented at the 47th Annual International Congress of the British Association of Paediatric Surgeons, Sorrento, Italy, July 18-21, 2000.

https://doi.org/10.1053/jpsu.2001.20705 Get rights and content

Abstract

Purpose: The aim of this study was to assess the impact of video assisted thoracoscopic surgery (VATS) in the management of empyema in children. Methods: This report involves cases of complicated pneumonia in children requiring surgical intervention after failure of medical treatment with antibiotics, with or without drainage from November 1997 to October 1999. The impact of VATS has been studied prospectively from October 1998 when VATS was introduced. The results have been compared with the previous year when similar cases were dealt with open thoracotomy. These 2 groups of patients with VATS (V) or without VATS (O) were studied for their progress in hospital and the final outcome. Results: A total of 39 immunocompetent children with community-acquired pneumonia were studied. There were 17 cases in O and 22 in V. There were 2 conversions to open thoracotomy in V. Both of these cases required resection of the lung parenchyma for severe necrosis and bronchopleural fistula. The mean age in years was 5.3 (O) and 4.9 (V). Parameters that were significantly less in V compared with O include timing of referral (O, 13.6 days; V, 5.3 days), number of lung resections (O, 8; V, 2), blood transfusion (O, 14; V, 2), analgesia requirements (O, 7.8 days; V, 2.9 days), postoperative length of stay in hospital (O, 10.4 days; V, 4.6 days), time to become normothermic (O, 5.6 days; V, 1.7 days); and time to removal of chest drains (O, 6.0 days; V, 2.7 days). Cosmesis is superior in cases of VATS compared with open thoracotomy. All the children recovered well on follow-up with resolution of symptoms and no recurrences. Conclusions: (1) VATS has ushered in a new era of hope for patients with complicated pneumonia. (2) Thoracotomy, lung resections, and the attending morbidity rate have decreased. (3) Patients are being referred earlier by the physicians because the management protocol is changing. J Pediatr Surg 36:316-319. Copyright © 2001 by W.B. Saunders Company.

Section snippets

Materials and methods

Thirty-nine consultations to the paediatric surgical service for intervention in empyema after failure of medical treatment were received during the period from November 1997 to October 1999. All these immunocompetent children had community-acquired pneumonia. All children had received appropriate intravenous antibiotics with or without thoracentesis. Surgical intervention was undertaken based on lack of clinical improvement or evidence of loculation, determined by computed tomography or

Results

The preoperative time, number of lung resections, need for blood transfusion secondary to intraoperative blood loss, analgesia requirements, time to become normothermic, duration of tube insertion, and postoperative length of stay in hospital for both groups are compared in Table 1.

. Comparison of Children Who Underwent Open Thoracotomy and VATS

Empty Cell	O	V	P Value
Number	17	22	—
Stage*	5:12	18:4	.003
Age (yr)	5.3 ± 0.64	4.9 ± 0.45	.86
Sex (M:F)	11:6	14:8	—
Preoperative (d)†	13.64 ± 1.1	5.27 ± 0.41	<.0001
Lung Resection‡	8	2††	.03

Discussion

Recently, there is a worldwide, although grossly underreported, increase in the number of loculated empyema resistant to conservative management.1, 6 Our hospital is the major tertiary referral centre for children in Southeast Asia, and we see approximately 30 cases of complicated pneumonia with empyema in children every year, in whom two thirds need surgical intervention (unpublished data). Before October 1998 when VATS was introduced in the surgical arm, all such cases were treated with open

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Cited by (56)

Surgical Management of Complicated Necrotizing Pneumonia in Children
2017, Pediatrics and Neonatology
Citation Excerpt :
The optimal surgical treatment for acute NP with empyema remains controversial. Some investigators recommend formal LB for most cases,3,4,8,11 whereas others suggest that LB is rarely necessary and prefer to perform DC to preserve lung parenchyma.12,13 Because the severity of NP is considerably influenced by the degree of necrosis, the treatment should be based on the severity of destruction and any associated complications.
There are no well-established indications for the surgical management of acute necrotizing pneumonitis in children. This study presents our experience regarding this challenging topic.
Between 2002 and 2009, 56 necrotizing pneumonitis patients with empyema were treated surgically. The outcomes were analyzed retrospectively. Computed tomography findings of massive lung necrosis or large cavities involving more than 50% of the involved lobe were deemed to be complicated necrotizing pneumonitis. Patients without the above indications were considered uncomplicated.
Thirty-one cases were uncomplicated and 25 were complicated. Operative procedures included 38 decortications (31 uncomplicated and seven complicated), 14 wedge resections, and four lobectomies (complicated only). Preoperatively, patients with complicated necrotizing pneumonia had a higher incidence of pneumothorax (32% vs. 14.3%; p = 0.001), endotracheal intubation (44% vs. 9.7%; p = 0.008), and hemolytic uremic syndrome (20% vs. 3.2%; p = 0.01). These patients also had higher incidences of intraoperative transfusion (68% vs. 9.7%; p = 0.03), major postoperative complications (16% vs. 0%; p = 0.02), reoperations (16% vs. 0%; p = 0.02), and longer postoperative stay (19.8 ± 24.2 days vs. 11.2 ± 5.8 days; p = 0.03). Four complicated patients, who initially had decortications and limited resections, underwent reoperations. Compared with uncomplicated patients, those who underwent decortications and wedge resection required longer postoperative stays (23.6 ± 9.9 days, p < 0.01 and 21.1 ± 30.7 days, p = 0.04, respectively), whereas patients who had lobectomy had a similar duration of recovery (9.0 ± 2.1 days, p = 0.23). All patients improved significantly at follow-up.
Children with complicated necrotizing pneumonitis have more preoperative morbidities, more major postoperative complications, and require longer postoperative stays. Aggressive surgical treatment results in significant clinical improvement. Lobectomy in patients with complicated necrotizing pneumonitis may shorten the postoperative course and avoid subsequent surgery.
Pediatric empyema: Outcome analysis of thoracoscopic management
2009, Journal of Thoracic and Cardiovascular Surgery
Thoracoscopy has become a favored modality in treating pediatric empyema. However, the factors affecting the outcome of thoracoscopic management remain unclear. In this study, we report our experience using thoracoscopy to treat empyema in pediatric patients and investigate the factors affecting outcome.
We retrospectively reviewed the demographic data, clinical presentation, radiographic findings, laboratory studies, and hospital course of 101 pediatric patients who underwent thoracoscopy for empyema between 1995 and 2008.
Empyema was due to pneumococcus infection in 64 patients (63.4%), and 69% of the cultured microorganisms were penicillin nonsusceptible. Chest computed tomography scan was performed in 96 patients, in whom necrotizing pneumonia was noted in 35 (36.5%). Preoperative intensive care unit admission was required for 33 patients (32.7%). Preoperative chest tube drainage was performed in 36 patients (35.6%), and thoracoscopy was used as the primary treatment in the remaining 65 patients. Complications occurred in 10 patients (9.9%); there were no mortalities. The median postoperative hospital stay was 13 days. Multivariate analyses showed that necrotizing pneumonia was significantly associated with the presence of complications, and that necrotizing pneumonia, preoperative intensive care unit admission, and preoperative chest tube drainage were independent risk factors for a longer postoperative hospital stay.
The clinical presentations of empyema in children requiring thoracoscopy are diverse. Patients with necrotizing pneumonia and those requiring preoperative intensive care unit admission and undergoing preoperative chest tube drainage are at high risk for developing complications and requiring longer hospital stay after thoracoscopy.
Efficacy of video-assisted thoracoscopic surgery in managing childhood empyema: a large single-centre study
2009, Journal of Pediatric Surgery
Citation Excerpt :
Several studies have evaluated VATS as a treatment modality for childhood empyema and they are summarised in Table 4. A nonrandomised study compared VATS with thoracotomy and the authors favoured VATS on the basis of reduced hospital stay, duration of postoperative antibiotics and chest drain requirements [26]. There are 2 randomised controlled trials evaluating the role of VATS in childhood empyema.
A randomised controlled trial evaluating the role of video-assisted thoracoscopic surgery (VATS) in childhood empyema reported a failure rate of 16.6%. Our aim is to determine the outcome of VATS in a large series of children managed by 3 paediatric surgeons experienced in endoscopic surgery.
A retrospective study of all children with empyema admitted under the care of the 3 surgeons between February 2004 and February 2008 was undertaken. Recorded details included demographic data, mode of presentation, preoperative investigations, operative details, antibiotic usage, microbiological data, postoperative course, follow-up data and complications.
114 children (69 boys, 45 girls) had VATS for empyema. Their median age was 5 (0.2-15) years. The pleural cavity was drained for a median of 4 (2-13) days. Median postoperative hospital stay was 7 (4-36) days. Median follow-up was 8 (1-24) months. There were 8 (7%) treatment failures: 5 conversions to thoracotomy and 3 recurrent empyemas. There were 7 complications (6%): air leak (n = 6) and lung injury (n = 1). 104 (91%) children had full resolution of symptoms. There were no deaths.
Video-assisted thoracoscopic surgery has a better outcome in childhood empyema than reported in a recent randomised trial and it has an important role in the management of this condition.
Pediatric parapneumonic pleural effusions: Experience in a university central hospital
2009, Revista Portuguesa de Pneumologia
Introdução: Os derrames pleurais podem complicar as pneumonias na população pediátrica. Assumem especial importância pelas implicações na duração do internamento, geralmente prolongado, e pela morbilidade associada.
Objectivos: Caracterizar uma população de doentes com pneumonia complicada de derrame; determinar os possíveis factores de prognóstico a partir de dados clínicos, radiológicos e analíticos na admissão; e avaliar a influência das intervenções terapêuticas na evolução da doença.
Métodos: Revisão casuística dos doentes com idade inferior a 18 anos e derrame pleural parapneu mónico, internados de Julho de 1997 a Junho de 2004 (7 anos).
Resultados: Foram estudados 118 casos, 60% do sexo masculino, com idade média 7 anos. A incidência de derrame pleural aumentou ao longo do período do estudo. Verificou-se maior incidência de casos no Outono e no Inverno. Na admissão, 60% dos doentes apresentavam sinais de dificuldade respiratória e 39% dor torácica. Em 40% dos doentes foram detectados septos pleurais na admissão, o que se associou a maior duração de internamento e de antibioticoterapia e mais frequente necessidade de cirurgia. Em 72% dos doentes foi efectuada toracocentese (pH médio: 7,24). Em 17% foi possível isolar o agente: Streptococcus pneumoniae (cinco), Staphylococcus aureus (quatro) e Streptococcus pyogenes (quatro). Foram submetidos a drenagem pleural 52% e necessitaram de cirurgia 18%. A mediana da duração de internamento foi de 15 dias e a média de 16,4 dias (2 a 51).
Discussão: Associam-se a pior prognóstico a presença de: sinais de dificuldade respiratória; septos; empiema; baixo valor no líquido pleural de pH, glicose ou proteínas; desidrogenase láctica elevada no líquido pleural e proteína C-reactiva sanguínea aumentada. A drenagem pleural e/ou cirurgia mais precoces provavelmente diminuem o tempo de doença e de internamento.
Conclusão: Os derrames parapneumónicos complicados são tratados com êxito em centros de referência com experiência nos diferentes tipos de intervenção que poderão ser necessários.
Rev Port Pneumol 2009; XV (2): 241-259
Introduction: Pleural effusions can complicate pneumonias in children and adolescents and are usually associated with a long hospital stay and increased morbidity.
Aims: To characterise a population of patients with parapneumonic pleural effusion and to establish possible prognostic factors on admission based on clinical, imaging and analytical data. To correlate treatment options with the outcome.
Methods: Case review of patients under 18 years old with parapneumonic pleural effusion, admitted between July 1997 – June 2004 (7 years).
Results: 118 patients were included, 60% male, with mean age 7 years. The incidence of pleural effusion increased throughout the period of the study. The admissions occurred predominantly in autumn and winter. On admission 60% of patients had respiratory distress and 39% chest pain. In 40% loculations were found on admission and were associated with longer hospital stay, longer course of antibiotic therapy and more frequent need for surgery. Thoracentesis was performed in 72% of patients (mean pH pleural fluid 7.24). The aetiologic agent was identified in 17% of cases: Streptococcus pneumoniae (five), Staphylococcus aureus (four) and Streptococcus pyogenes (four). In our study, 52% of patients underwent pleural drainage and 18% surgery. Median length of hospital stay was 15 days with mean 16.4 days (2 – 51).
Discussion: Factors associated with worse prognosis were respiratory distress, loculations, empyema, low pH in pleural fluid, glucose or proteins in pleural fluid, high lactic dehydrogenase level in pleural fluid and high serum C-reactive protein. Pleural drainage and/or surgery can shorten hospital stay and improve outcome.
Conclusion: Complicated parapneumonic pleural effusions are managed successfully in centres with experience in the different types of procedure that might be necessary.
Rev Port Pneumol 2009; XV (2): 241-259
Community-acquired parapneumonic effusion in children: what's new?
2007, Archives de Pediatrie
Les pleurésies purulentes communautaires de l'enfant sont une complication sévère des pneumopathies. Il semble y avoir une augmentation de leur incidence depuis le début des années 1990. La morbidité y est importante : durées d'hospitalisations prolongées, actes invasifs fréquents et parfois répétés. Malgré tout, il n'existe pas à l'heure actuelle de consensus sur la prise en charge. L'une des raisons est l'absence de résultats significatifs dans les nombreuses études menées chez l'enfant. L'absence d'une classification consensuelle est un frein majeur à la qualité de ces études. La mise au point d'une telle classification devrait être un préalable à toute étude de grande envergure. En attendant, une harmonisation de l'antibiothérapie (association de molécules synergiques à hautes doses et à bonne pénétration pleurale) et une remise en question du drainage thoracique semblent être les mesures qui pourraient améliorer la prise en charge de cette affection.
Community-acquired pleural infection is a life-threatening complication of pneumonia in children. It seems to be more prevalent actually. This pathology is associated with an high morbidity and frequently requires prolonged hospitalization and invasives procedures. However, there is no consensus on its management in pediatrics, especially because of the lack of trials. To improve the quality of the future studies and to compare the series, a child-adapted classification is required. To date, in attempt of evidence, chest drainage or thoracocentesis-thoracoscopy are questionable. For treatment, high regimens of synergic and intravenously-delivered antibiotics seem to be the better choice.
Video-Assisted thoracoscopic surgery for pediatric empyema by two-port technique: A single-center experience with 167 consecutive cases
2017, Journal of Indian Association of Pediatric Surgeons

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^☆: Address reprint requests to Ramnath Subramaniam, Associate Consultant, Department of Paediatric Surgery, K.K. Women and Children's Hospital, 100, Bukit Timah Rd, Singapore 229899.

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Experience with video-assisted thoracoscopic surgery in the management of complicated pneumonia in children☆

Abstract

Section snippets

Materials and methods

Results

Discussion

J Pediatr Surg

J Thorac Cardiovasc Surg

J Pediatr Surg

J Pediatr Surg

Chest