Management of Empyema Thoracis inChildren: Tube Thoracostomy VersusEarly DecorticationEmpiema toraks merupakan keadaan yang sering terjadi akibat komplikasi tindakan pembedahan dari pneumonia. Hal ini merupakaan keadaan yang sangat mempengaruhi morbiditas pediatric. Berbagai cara pengobatan telah dijabarkan untuk mengatasi kondisi tersebut. Namun, pengobatan untuk tatalaksana empiema thorakis pada anak masih merupakan perdebatan. Angka kejadian empiema toraks terus meningkat sehingga memiliki angka mortalitas yang tinggi (10-16%). Hal ini terjadi saat bakteri menginvasi dan menyebar ke dalam rongga pleura yang normal. Proses ini terjadi dalam tiga fase. Fase ekseduatif disebabkan oleh peingkatan permeabilitas inflamasi pleura. Fase firbunopurulen ditandai dengan peningkatan pengendapan fibrin, yang mengakibatkan lokulasi dan akumulasi pus. Fase organisasi dimulai satu minggu yang ditandai dengan terjadinya pembentukan kulit fibrinosa pada membran pleura, membentuk jaringan yang mencegah ekspansi pleura dan membentuk lokulasi intrapleura yang menghalangi jalannya tuba torakostomi untuk drainase. Kulit pleura yang kental terbentuk dari resorpsi cairan dan merupakan hasil dari proliferasi fibroblas. Parenkim paru menjadi terperangkap dan terjadi pembentukan fibrotoraks. Bakteri utama yang menyababkan antara lain staphylococcus, streptococcus, dan mycoplasma.Pneumonia bacterial merupakan penyebab terbanyak dari empiema toraks pada pasien anak. Terdapat beberapa pilihan pengobatan namun sayangnya hasil dari beberapa tes regimen sangat bervariasi. Bagaimanapun, alternative pengobatan empiema tanpa operasi There are many treatment options but unfortunatelyresults with these treatment regimens have beenhighly variable. As a result, the optimum therapeuticstrategy for empyema has yet to be elucidated.Moreover, the availability of non-operativealternatives frequently results in delayed surgicalconsultation, and ultimately, increased patientmorbidity and mortality.8,9,10 Determination of thestage of the empyema has been reported to becrucial in choosing an appropriate therapeutic option.Duration of symptoms has been suggested as oneof the means of estimating the stage of theempyema.9In complicated para-pneumonic effusion, both serialthoracentesis and chest tube drainage can beadvocated as a first-line therapy. There have beensome reports of the effectiveness of this procedureafter early diagnosis.11,12 Tube drainage isrecommended in children because of its reliability,rather than multiple thoracentesis.13 Pleural lavagevia the chest tube is useful for augmenting drainageand mechanical clearance and various antimicrobialagents can be added to the washing fluid.8,11 LeMenseet al14 have suggested that this decreases the severityof pleural sepsis while instituting further therapy.We have not used any agent for lavage purposesafter chest tube placement.Because of the low reported success rate of tubethoracostomy for loculated empyema, alternativeapproaches have been developed. Intrapleuralfibrinolytic agents (IPFA) have been used in thetreatment of thoracic empyema.15 Several reportshave documented successful drainage of multiloculatedempyema using streptokinase andurokinase.13,16 Temes17 used IPFA in all 26 patientssent for decortication. More than two-thirds of patientswith traditional indication for decortication forempyema thoracis were treated successfully. Wehave no experience of using this mode of treatmentwhich appears feasible in early stages of the disease.The presence of a thick rind with trapped lung areindications for operation and decortication.8,11,14 Theinability to evacuate fibrinous debris via chest tubeis also an indication for decortication. Decorticationshould be performed as soon as possible if drainageis not effective. It may be an initial treatment insteadof wasting time by performing tube thoracostomy.When the patient's status is suitable for surgery, werecommend this approach because of the decreasein mortality and morbidity, reduction of hospital stay,and discharge of the patient without an open wound.Postoperative complications such as atelectasis anddelayed expansion are mainly from parenchymaldisease. The results of our study are comparable tothat of Brohi et al18 but are somewhat different fromthat of Light et al.105. Majid F, Zubair M. Management of empyema thoracis in children: tube thoracostomy versus early decortication. Journal of Surgery Pakistan (International). 2011

Management of Postpneumonic Empyemas in ChildrenParapneumonic effusion is any pleural effusion secondaryto pneumonia (bacterial or viral) or lung abscess.Approximately 0.6% of childhood cases of pneumoniaare complicated by the formation of pleural empyema.The incidence of empyema ranges from 4 to 6 per100,000 children (1). It is recommended that a stepwiseapproach be taken with patients with parapneumoniceffusions. The treatment options are observation, therapeuticthoracentesis, tube thoracostomy, tube thoracostomywith intrapleural fibrinolytics, thoracoscopy andthoracotomy with decortication, and open drainageprocedures. Unfortunately, results with these treatmentregimens have been highly variable (2, 3). The aim ofthis study was to assess different treatment options in themanagement of postpneumonic pediatric empyemas.DiscussionLow socio-economic level, delay in diagnosis of pneumonia,unsuitable antibiotic treatment, immunodeficiencyand malnutrition are contributing factors to the developmentof empyema in patients with pneumonia.Bacterial pneumonia is the most common cause ofpleural effusions or empyema in the pediatric agegroup (2, 3). The treatment of empyema in children stillremains controversial. However, the treatment objectivesoutlined by MAYO (5) are 1) to save life, 2) to eliminatethe empyema, 3) to re-expand the trapped lung,4) to restore mobility to the chest wall and diaphragm,5) to return the respiratory function to normal, 6) toeliminate complications or chronicity, and 7) to reducethe duration of hospital stay.The reported rate of identifying an infectious organismfrom pleural fluid varies markedly, from 8% to 76%.However, in present day practice, pleural fluid culture isoften negative due to use of antibiotics before obtaininga pleural fluid sample (6). In our study, pleural fluid cultureswere positive in 49.55% of the patients. As in manyother studies (1, 3, 6, 7) the most frequently identifiedmicro-organism in our study was Staphylococcusaureus.Chest tube thoracostomy is considered to be theappropriate treatment modality for stage II thoracicempyema (especially for non-multiloculated cases). TheBritish Thoracic Society recommends that all patientswith significant pleural infection should be treated withantibiotics and drainage of the pleural fluid (6). In manystudies the rate of success of chest tube thoracostomywas reported as being between 61% and 100% (8-12).Chest tube thoracostomy rate of success was 89.9% inour study. Although chest tube thoracostomy is a treatmentwith a high rate of success, the hospital stay islong. This period is reported to be approximately 8-14days (range 3-35 days) in the literature (8-10, 12, 13).Likewise in the present study, the duration of hospitalstay in group I was 11.46 3.79 days (range 6-22 days).The hospital stay and chest tube removal time in group Iwas a little longer than in group II, however there was nostatistically significant difference between the twogroups (P = 0.040, P = 0 .019 respectively).We applied fibrinolytic treatment with chest tube thoracostomyto patients in whom multiloculation wasfound by US and CT. Intrapleural fibrinolytic drugs maylyse the fibrinous strands in loculated empyemas.Several reports have documented successful drainage ofmultiloculated empyema using streptokinase and urokinase(11, 14-17). However, MASKELL and associates (18)reported that (multi-centre, randomised, double-blindstudy) there was no benefit from streptokinase in termsof mortality, rate of surgery, radiographic outcomes, orduration of the hospital stay. Moreover BALCI et al. (7)have concluded that fibrinolytic treatment is not an alternativeto surgery, especially in loculated empyemas inchildren. We have performed tube thoracostomy withintrapleural fibrinolytic treatment on 22 patients. Nine(40.9%) of them were successful and 13 (59.1%), onwhom treatment was unsuccessful, underwent decortication.Both BALCI et al. (7) and MASKELL and associates(18) agreed that fibrinolytic treatment does notreduce hospital stay or the need for surgery.Video-assisted thoracoscopic surgery (VATS)achieves debridement of fibrinous pyogenic material,breakdown of loculations, and drainage of pus from thepleural cavity under direct vision. Many authors havereported that VATS can be performed safely and effectivelyin children with stage II empyema. In addition,VATS was associated with a lower mortality rate, loweropen surgery rate, shorter hospital stay, and chest tubedrainage, compared with non-operative treatment (1, 2,11, 18, 19). Unfortunately we do not have any experiencewith VATS.Decortication has to be performed on patients whereconservative treatment is radiologically and clinicallyproven to be insufficient. We applied decortication on 19of our patients (9 of group I and 10 of group II patients)who did not show clinical recovery and who had thickpleural peel with trapped lung and multiple loculationsat control CT. The chest tube removal time was 5.00 2.43 days and hospital stay was 6.32 2.54 days ingroup III. Both OZCELIK and associates (3) and POTHULAet al. (20) have reported that decortication decreaseschest tube drainage and hospital stay. In addition, decorticationhas low morbidity and mortality rates (3, 7, 20).

Dapus3. OZCELIK C., LK R., ONAT S., OZCELIK Z., INCI I., SATICI O.Management of postpneumonic empyemas in children. Eur JCardiothorac Surg, 2004, 25 : 1072-1078.7. BALCI A. E., EREN S., LK R., EREN M. N. Management of multiloculatedempyema thoracis in children : thoracotomy versusfibrinolytic treatment. Eur J Cardiothorac Surg, 2002, 22 : 595-598.A. Kosar, M.D.Sureyyapasa Chest Disease and Chest Surgery Training and ResearchHospitalDepartment of Thoracic SurgeryAtaturk cad. Murat Apt. 46/1634734 Erenkoy, Istanbul, TurkeyTel. : + 90 216 386 35 90Fax : + 90 216 459 68 59E-mail : altugkosar@yahoo.com

The Changing Face of Pleural Empyemas in Children: Epidemiologyand ManagementL. Kaplan and Mary L. BrandtKaren D. Schultz, Leland L. Fan, Jay Pinsky, Lyssa Ochoa, E. O'Brian Smith, Sheldon Pediatrics 2004;113;1735journal of the American Academy of Pediatrics

St. Peter SD, Tsao K, Harrison C, et al. Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomised trial. J Pediatr Surg 2009;44:106-111.

Kalfa N, Allal H, Lopez M, et al. Thoracoscopy in pediatric pleural empyema: a prospective study of prognostic factors. J Pediatr Surg 2006;41:1732-7.

Jaffe A, Calder AD, Owens CM et al. Role of routine computed tomography in paediatric pleural empyema. Thorax 2008;63:897-902.

Spencer DA, Iqbal SM, Hasan A, et al. Empyema thoracis is still increasing in UK children. BMJ 2006;332:333.