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To the Editor.—
The review by Avansino et al1 addresses the important management question of what treatment to offer children with pleural collections complicating pneumonia.
It is unfortunate that the authors performed a meta-analysis without assessment of study quality. Appropriate meta-analysis would examine prospective controlled studies, preferably with randomization, with analysis of outcomes according to intention to treat. This would have resulted in inclusion of only 22,3 of the 54 studies listed in their Table 1 and 12 of the 25 studies listed in their Table 2, almost certainly yielding different results from those described. The remainder of the studies included are observational, descriptive, or retrospective reviews of medical charts. In addition, it is unclear why the study by Thomson et al,4 the only prospective, double-blind, randomized, placebo-controlled trial in this field, is cited in the reference list but not included in the tables contributing to the meta-analysis. This study demonstrates benefit of fibrinolytic therapy over chest-tube drainage alone.
The key question remains as to whether surgical treatment should be offered in preference to a chest tube with fibrinolysis as primary treatment for pediatric pleural empyema. If we do use this study's observational data, length of stay is similar for primary fibrinolytic therapy compared with thoracotomy and video-assisted thoracoscopic surgery at 10.7 vs 10.6 vs 11.2 days, respectively. Of the fibrinolysis cases, 9.4% "failed," requiring an operative procedure that is compared with those in the operative group who return for a second operation 
3% of the time. For an equivalent length of stay, the group of children undergoing fibrinolysis as primary treatment underwent one tenth the number of operations.
The only conclusion that can be drawn from the plethora of observational studies reviewed in the article by Avansino et al is the suggestion that thoracotomy and thoracoscopic surgery for pediatric empyema seem safe, with no reported mortality and little morbidity. The authors note potential publication bias and acknowledge the potential weaknesses of included studies yet still make the overstatement that "primary operative therapy compared favorably with nonoperative approaches." It would be more correct to assert that there are an insufficient number of appropriately performed studies to answer the question.
The choice to review observational studies with their inherent methodologic flaws rather than to examine prospectively performed randomized, controlled studies renders this article useful as a historical curiosity only, not one on which clinicians should rely to make patient-management decisions.
REFERENCES
This article has been cited by other articles:
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  S. S. Shah, C. M. DiCristina, L. M. Bell, T. Ten Have, and J. P. Metlay Primary Early Thoracoscopy and Reduction in Length of Hospital Stay and Additional Procedures Among Children With Complicated Pneumonia: Results of a Multicenter Retrospective Cohort Study Arch Pediatr Adolesc Med, July 1, 2008; 162(7): 675 - 681. [Abstract] [Full Text] [PDF]
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