Making the transition from video-assisted thoracoscopic surgery to chest tube with fibrinolytics for empyema in children: Any change in outcomes?

Livingston, Michael H.; Colozza, Sara; Vogt, Kelly; Merritt, Neil; Bütter, Andreana

doi:10.1503/cjs.014714

Cited by 12 publications

(4 citation statements)

References 17 publications

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“…The procedures done were mostly lung biopsy (25.0%), lobectomy (22.7%), decortication (20.9%), resection of mediastinum mass (6.8%), lung metastasectomy (6.8%), lymph node biopsy (4.5%), diagnostic thoracoscopy (4.6%), cyst excision (4.6%), diaphragmatic hernia repair (2.3%) and thymectomy (2.3%). Thoracic empyema was first disease in which the thoracoscopic approach used [41,42]. Following failure of initial conservative therapy with chest tube drainage and antibiotics, early thoracoscopic decortication is advised [43].…”

Section: Discussionmentioning

confidence: 99%

Pediatric Thoracoscopy: Ten Years Experience in Tertiary Hospital

Alharbi,

Almatrfi,

Bawazir

2023

IJPS

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Purpose: A minimally invasive Thoracoscopic Surgery (TS) offers several options in diagnosis and surgical treatment in pediatric surgery. This study evaluates experience and outcome of thoracoscopic surgery in pediatrics during 10 years period in tertiary hospital. Patients and methods: This retrospective study conducted at King Faisal Hospital and Research Center, Jeddah, Saudi Arabia from 2012 to 2022. Data of 43 patients who underwent TS were enrolled. Data include patient’s demographic characteristics, co-morbidity, diagnosis, type of thoracoscopic procedures, time of intervention, length of hospital stay, post-operative complications. Results: Mean age of patients was 4.99 years. Females were more than males (55.8 vs. 44.2%). Sixteen (37.2%) patients had comorbidities. Thoracoscopic proce- dures were feasible in 43 children and adolescents with chest diseases including lung empyema (20.9%), congenital lobar emphysema (14.0%), interstitial lung disease (14.0%), congenital pulmonary airway malformation (11.6%), mediastinal mass (9.3%), lung metastasis (11.6%), lymphoma (4.7%), chronic inflamma- tions (7.0%), hemothorax (2.3%), bronchogenic cyst (2.3%), pleural effusion (2.3%) and pulmonary sequestration and right diaphragmatic hernia (2.3%). Proce- dures were made mostly for lung biopsy (25.0%), lobectomy (22.7%), decortication (20.9%), mediastinum mass resection (6.8%), lung metastasectomy (6.8%), lymph node biopsy (4.5%), diagnostic (4.6%), cyst excision (4.6%), diaphragmatic hernia repair (2.3%) and thymectomy (2.3%). Duration of hospital stay ranged from 2-180 days. All of the cases had chest drain (100.0%) and some of them required post-operative intubations (30.2%). Conversion rate to open was (4.7%). Complications were pneumothorax (7.0%), bleeding (2.3%) and air leak (2.3%). Conclusions: Thoracoscopic approach is a challenging method for diagnosis and treatment in pediatrics. However, complications were reported as pneumo- thorax, bleeding and air leak. In order to improve results, conversion rates, and the capacity to handle thoracoscopic complications, proper training is crucial.

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Section: Discussionmentioning

confidence: 99%

Pediatric Thoracoscopy: Ten Years Experience in Tertiary Hospital

Alharbi,

Almatrfi,

Bawazir

2023

IJPS

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“…In sharp contrast to adults, retrospective studies of VATS in pediatric patients with empyema ( Avansino et al, 2005 ; Chibuk et al, 2011 ; Cohen et al, 2012 ; Cohen et al, 2013 ), showed minimal mortality (n = 101) ( Chen et al, 2009 ). While there is still a debate regarding whether VATS is more expensive than IPFT ( Sonnappa et al, 2006 ; Cohen et al, 2008 ; St Peter et al, 2009 ) or not ( Shah et al, 2010 ; Derderian et al, 2020 ), the latter is advocated for by some as the preferred initial treatment of empyema in pediatric patients ( Livingston et al, 2016b ; Derderian et al, 2020 ). IPFT in pediatric practice is remarkably effective but still empiric.…”

Section: Treatment Of Pediatric Empyema With Minimal Mortality: An Example Of the Trendmentioning

confidence: 99%

“…IPFT with single chain tissue-type plasminogen activator (tPA, Alteplase) was more effective than saline irrigation ( Hanson et al, 2015 ). Meta-analysis ( Pacilli and Nataraja, 2018 ) and multiple studies have demonstrated equivalent efficacy between VATS and IPFT with urokinase (uPA) ( Sonnappa et al, 2006 ; Marhuenda et al, 2014 ; Sonnappa, 2015 ; Pacilli and Nataraja, 2018 ) or tPA ( St Peter et al, 2009 ; Livingston et al, 2016b ) in treatment of empyema in pediatric patients. As a result, IPFT is recommended as the first line treatment for empyema in pediatrics ( St Peter et al, 2009 ; Kobr et al, 2010 ; Stefanutti et al, 2010 ; Slaats et al, 2019 ; Baram and Yaldo, 2020 ; Livingston et al, 2020 ).…”

Section: Treatment Of Pediatric Empyema With Minimal Mortality: An Example Of the Trendmentioning

confidence: 99%

“…While patient mortality is negligible, the rate of IPFT failure in pediatric empyema remains around 15% ( Sonnappa et al, 2006 ; St Peter et al, 2009 ; Livingston et al, 2016b ; Long et al, 2016 ; Derderian et al, 2020 ). Defining reliable molecular predictors of treatment failure ( Arnold et al, 2012020 ; Derderian et al, 2020 ; Khemasuwan et al, 2018 ; Livingston et al, 2016a ) would therefore likely increase the efficacy of IPFT as a therapy for empyema in pediatrics.…”

Section: A Call For Novel Approaches To Assess the Likelihood Of Success Of Ipftmentioning

confidence: 99%

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From Bedside to the Bench—A Call for Novel Approaches to Prognostic Evaluation and Treatment of Empyema

et al. 2022

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Empyema, a severe complication of pneumonia, trauma, and surgery is characterized by fibrinopurulent effusions and loculations that can result in lung restriction and resistance to drainage. For decades, efforts have been focused on finding a universal treatment that could be applied to all patients with practice recommendations varying between intrapleural fibrinolytic therapy (IPFT) and surgical drainage. However, despite medical advances, the incidence of empyema has increased, suggesting a gap in our understanding of the pathophysiology of this disease and insufficient crosstalk between clinical practice and preclinical research, which slows the development of innovative, personalized therapies. The recent trend towards less invasive treatments in advanced stage empyema opens new opportunities for pharmacological interventions. Its remarkable efficacy in pediatric empyema makes IPFT the first line treatment. Unfortunately, treatment approaches used in pediatrics cannot be extrapolated to empyema in adults, where there is a high level of failure in IPFT when treating advanced stage disease. The risk of bleeding complications and lack of effective low dose IPFT for patients with contraindications to surgery (up to 30%) promote a debate regarding the choice of fibrinolysin, its dosage and schedule. These challenges, which together with a lack of point of care diagnostics to personalize treatment of empyema, contribute to high (up to 20%) mortality in empyema in adults and should be addressed preclinically using validated animal models. Modern preclinical studies are delivering innovative solutions for evaluation and treatment of empyema in clinical practice: low dose, targeted treatments, novel biomarkers to predict IPFT success or failure, novel delivery methods such as encapsulating fibrinolysin in echogenic liposomal carriers to increase the half-life of plasminogen activator. Translational research focused on understanding the pathophysiological mechanisms that control 1) the transition from acute to advanced-stage, chronic empyema, and 2) differences in outcomes of IPFT between pediatric and adult patients, will identify new molecular targets in empyema. We believe that seamless bidirectional communication between those working at the bedside and the bench would result in novel personalized approaches to improve pharmacological treatment outcomes, thus widening the window for use of IPFT in adult patients with advanced stage empyema.

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