Declining frequency of thoracoscopic decortication for empyema — redefining failure after fibrinolysis

Background Primary fibrinolysis for pediatric empyema has become standard of care at our institution. Early study of our protocol revealed a 16% thoracoscopic decortication rate after primary fibrinolysis. We now report the frequency with which children progress to operation with maturation of the protocol. Methods A database of patients diagnosed with empyema between September 2014 and March 2019 was examined. Patients who underwent tissue plasminogen activator (tPA) therapy with or without subsequent video-assisted thoracoscopic (VATS) decortication were included. Patients with additional indications for tube thoracostomy or VATS were excluded. Results Forty-eight patients were included. Median age was 4.5 years [IQR 2–9.3]. Median length of stay (LOS) was 8 days [IQR 6–11]. No patients underwent primary VATS. Median days with a chest tube was 5 [IQR 5–6] and median number of doses of tPA was 3 [IQR 3–3]. Seven patients (14.6%) had a chest tube replaced without undergoing VATS. The VATS rate was 4.2% in the first half of this study but 0% in the last 33 months. Conclusion Thoracoscopic decortication is rarely necessary in children with empyema. Raising the threshold for surgical intervention and utilizing further nonoperative measures can avoid an operation in most children without increasing in-hospital length of stay. Level of evidence IV