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ARTICLES:
Beth A. Kurt, Kimberly M. Winterhalter, Robert H. Connors, Bradford W. Betz, and John W. Winters
Therapy of Parapneumonic Effusions in Children: Video-Assisted Thoracoscopic Surgery Versus Conventional Thoracostomy Drainage
Pediatrics 2006; 118: e547-e553 [Abstract] [Full text] [PDF]
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[Read P3R] The jury is still out
Michael J Weinstein   (7 September 2006)

The jury is still out 7 September 2006
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Michael J Weinstein,
Pediatrician
The Hospital for Sick Children; University of Toronto

Send letter to journal:
Re: The jury is still out

michael.weinstein{at}sickkids.ca Michael J Weinstein

The authors are to be commended for performing one of the few prospective, randomized studies addressing the treatment of parapneumonic effusions. In this well-conducted, albeit small study, the authors found that outcomes (primarily length of hospital stay and duration of chest tube drainage) were superior in the VATS group compared to the group treated with conventional thoracostomy tube drainage and conclude that “the best course of action may be to do VATS for all parapneumonic effusions that require a drainage procedure”.(1)

Based on the evidence published to date, this recommendation appears premature. In the study by Kurt et al, VATS was found to be superior to conventional chest tube drainage. A much more relevant comparison, however, would have been to compare VATS with primary intrapleural fibrinolytic therapy. In the largest prospective study to date in children, children treated with primary intrapleural fibrinolytic therapy utilizing urokinase instilled through a small chest tube had a length of stay of 6 days. (2) This is similar to the VATS group in the current study (5.8 days). In our center, children treated with intrapleural tissue plasminogen activator soon after chest tube insertion had a drain in situ for approximately 3.5 days,(3) not appreciably different from the duration of chest tube drainage in VATS group in the current study (2.8 days). Moreover, thoracostomy plus fibrinolytic therapy is likely to be much more cost effective than VATS assuming relatively similar lengths of stay.(4) Other outcomes, such as caregiver preferences also important to determine.

The results of a prospective randomized trial comparing primary intrapleural fibrinolytic therapy versus VATS are needed before clinicians can comfortably recommend one treatment over another. VATS will very likely still have a role to play in this condition, but until clear evidence is available, VATS is still a procedure in search of a broad indication.

1. Kurt BA, Winterhalter KM, Connors RH, et al. Therapy of parapneumonic effusions in children:video-assisted thorascopic surgery versus conventional thoracostomy drainage. Pediatrics 2006; 118: 547-553. 2. Thomson AH, Hull J, Kumar MR, et al. Randomized trial of intrapleural urokinase in the treatment of childhood empyema. Thorax 2002; 57:343-347. 3. Weinstein M, Restrepo R, Chait PG, et al. Effectiveness and safety of tissue plasminogen activator in the management of complicated parapneumonic effusions. Pediatrics 2004; 113(3):e182-185. 4. Gates RL, Hogan M, Weinstein S, et al. Drainage, fibrinolytics or surgery: a comparison of treatment options in pediatric empyema. J Pediatr Surg 2004; 39:1638-1642.

Conflict of Interest:

None declared