Empyema thoracis, an accumulation of infected fluid in the thoracic cavity is known since Hippocrates time.¹ Children often present with persisted fever associated with respiratory distress, cough and occasionally chest pain. Empyema thoracis is seen all over world with increasing incidence and still significant cause of pediatric morbidity and mortality, especially in developing country.^2,3,4 The American Thoracic Society has described diagnostic criteria and three stages of empyema - exudative, fibrinopurulent and organized - based largely on characteristics of the plueural cavity contents.⁵

Pleural fluid and empyema are known complications of community acquired bacterial pneumonia. Effusion occurs in at least 0.4% of bacterial pneumonias, with up to 0.6 % of effusion resulting in the formation of empyema in all age groups.⁴ There is little consensus on its treatment. Tube thoracostomy and antibiotic usually suffice for stage - I empyema, but more needs to be done for progressed empyema. Progression of empyema with the development of fibrinous adhesions and multiloculations leading to simple pleural drainage more difficult or impossible.

In the recent literatures, there has been a trend toward early decortications for empyema thoracis with some authors^2,3,4,7,9 recommending early thoracotomy and decortication for refractory and symptomatic empyema thoracis.

The proper assessment of the response to conservative treatment, the clinical status of the child and correct evaluation of the stage the disease is crucial in deciding the mode of further surgical intervention. In stage II - III empyema, tube thoracostomy may fail to clear the infected fluid in multiloculated, chronic bilateral empyema, and thickened pleura with encased lung.² Standard posterolateral thoracotomy and decortication is our treatment of choice for all children with stage II – III empyema.

The present study is aimed to evaluate safety, effectiveness, operative finding and outcomes by thoracotomy and decortication in the management for stage II - III empyema thoracis in children.

Aims and Objectives:

In this study, we aimed to evaluate the safety, effectiveness, operative findings and outcomes of thoracotomy and decortication for stage II - III empyema thoracis in children.

This was a retrospective observational study in the children, who underwent thoracotomy and decortication for stage II - III empyema thoracis during the study period from January 2013 to December 2024 in our institution. The demographic characteristics of the patients were noted. Respiratory distress, fever, cough and occasional chest pain were the most common symptoms. The diagnosis of empyema was based on clinical symptoms and chest radiographs finding [Fig. I (A and B)] and were confirmed by pus in needle thoracocentesis. Aspirated pus by needle thoracocentesis sent for culture and sensitivity test. Patients were investigated with complete hemogram, coagulation profile and serum proteins. Tube thoracostomy was performed to all the patients after diagnosis to reduce septic load. In refractory and symptomatic empyema thoracis patients following tube thoracostomy were further evaluated with computed tomography of chest [Fig. I (C and D)]. Inclusion Criteria: All presented empyema thoracis patients (pus on needle aspiration from the thoracic cavity) with persistent symptoms and computed tomography reveals presence of pleural debris, multiloculated pus, debris, air fluid level, thick pleural peel with encased lung [Fig. II (A and B) and (C and D) after tube thoracostomy were included in the study. Exclusion Criteria: Post-traumatic and tubercular patients were excluded from the study. All the patients were undergone standard posterolateral thoracotomy and complete formal decortication of lung. Post-operatively adequate antibiotic and analgesic were given intravenously till good oral intake resumed. Antibiotics were changed depending upon the culture and sensitivity report of the pus/ debris sent at the time of needle thoracocentesis and surgery. Patients were started stream inhalation, chest physiotherapy and encouraged to perform early incentive spirometry. Chest tube drainage was observed for output and checked chest x-ray was taken after 48 hours post-operatively to look for lung re-expansion. The patients were followed up for 1 month to 1 year. Surgical Technique: The patients were placed laterally with the affected side up and the intercostals spaces increased by bolster under the chest and arm lifted up. Surgery was performed with standard posterolateral thoracotomy with rib excision through the 4th and 5th intercostal space. The pleural space was entered after excision of thick parietal pleura and pus sample taken for culture and sensitivity. [Fig. III (A, B, C and D)] Loculi are broken and the entire pleural space thoroughly debrided with removal of pus and debris, but there was no inclination for the lung to re-expand without formal decotication [Fig. IV (A and B)]. The thick visceral pleural peel is carefully and meticulously removed from the surface of the entire lung releasing the encased lung [Fig. V (A and B)]. As the decortication was performed early, the peel was often pliable and stripped away from lung and chest wall without major air leak or substantial blood loss. Re-expansion of trapped areas of lung was assessed by manual ventilation [Fig. V (C and D)]. Lung re-expansion was immediate and quite gratifying in all patients. All significant air leaks are meticulously closed using absorbable sutures [Fig. VI (A and B)]. Thoracic cavity is irrigated thoroughly with normal saline. Chest tube drain was placed, ribs approximated and thoracotomy wound closed in layer after giving an intercostals block. Fig. VII (A and B) shows specimen of removed pus and debris along with excised rib and (C and D) shows removed thickened visceral pleural peel and debris. Fig. VIII (A and B) shows children were extubated in the operating room after completion of operation. Data Collection: The patient’s demographics, clinical presentations, operative findings, operative time, length of hospital stay and outcomes were recorded from hospital records Statistical Analysis: Descriptive statistical analysis was done and results were presented in terms of frequency and percentages. Informed written signed consent was taken from the patient’s parent after explaining for them regarding the nature of surgery, the outcome and possible complications. Figure I. (A and B): X-Ray of Patients with Left and Right Sided Emmpyema Thoracis before Tube Thoracostomy Showing Complete Opacity of One Sided Hemithorax and (C and D) after 72 Hours of Tube Thoracostomy with Loculation, Thick Pleural Peel not Allowing Full Expansion of Left and Right Lung Figure II. (A and B): Computed tomography scan of chest in left sided empyema and (C and D) Computed tomography scan of chest in right side empyema of same patient shows multiloculated pus and air, thick pleural peel and trapped lung Figure III. ( A, B, C and D): Operative views after entry to thoracic cavity shows pus and debris of empyema patients Figure IV. (A and B): Operative views after entry to thoracic cavity and removal of enitre pus and debris from the thoracic cavity with non-visible lung and no inclination to reexpansion before formal decotication Figure V. (A and B): Operative views shows thickened visceral pleural peel with encasement of underlying lung and (C and D): shows complete re-expansion of trapped lung after complete removal of entire thickened visceral pleural peel, confirmed with manual positive pressure ventilation Figure VI. (A and B): Operative views shows major significant air leaks closure using absorbable sutures, confirmed during reexpansion of trapped lung with manual positive pressure ventilation Figure VII. (A and B): Shows specimen of removed pus and debris along with excised rib and (C and D) shows removed thickened visceral pleural peel and debris. Fig. VIII (A and B) shows children were extubated in the operating room after completion of operation.

This was a retrospective observational study in the children, who underwent thoracotomy and decortication for stage II - III empyema thoracis during the study period from January 2013 to December 2024 in our institution.

The demographic characteristics of the patients were noted. Respiratory distress, fever, cough and occasional chest pain were the most common symptoms. The diagnosis of empyema was based on clinical symptoms and chest radiographs finding [Fig. I (A and B)] and were confirmed by pus in needle thoracocentesis. Aspirated pus by needle thoracocentesis sent for culture and sensitivity test.

Patients were investigated with complete hemogram, coagulation profile and serum proteins. Tube thoracostomy was performed to all the patients after diagnosis to reduce septic load.

In refractory and symptomatic empyema thoracis patients following tube thoracostomy were further evaluated with computed tomography of chest [Fig. I (C and D)].

Inclusion Criteria:

All presented empyema thoracis patients (pus on needle aspiration from the thoracic cavity) with persistent symptoms and computed tomography reveals presence of pleural debris, multiloculated pus, debris, air fluid level, thick pleural peel with encased lung [Fig. II (A and B) and (C and D) after tube thoracostomy were included in the study.

Exclusion Criteria:

Post-traumatic and tubercular patients were excluded from the study.

All the patients were undergone standard posterolateral thoracotomy and complete formal decortication of lung.

Post-operatively adequate antibiotic and analgesic were given intravenously till good oral intake resumed.

Antibiotics were changed depending upon the culture and sensitivity report of the pus/ debris sent at the time of needle thoracocentesis and surgery.

Patients were started stream inhalation, chest physiotherapy and encouraged to perform early incentive spirometry.

Chest tube drainage was observed for output and checked chest x-ray was taken after 48 hours post-operatively to look for lung re-expansion.

The patients were followed up for 1 month to 1 year.

Surgical Technique:

The patients were placed laterally with the affected side up and the intercostals spaces increased by bolster under the chest and arm lifted up. Surgery was performed with standard posterolateral thoracotomy with rib excision through the 4^th and 5^th intercostal space.

The pleural space was entered after excision of thick parietal pleura and pus sample taken for culture and sensitivity. [Fig. III (A, B, C and D)] Loculi are broken and the entire pleural space thoroughly debrided with removal of pus and debris, but there was no inclination for the lung to re-expand without formal decotication [Fig. IV (A and B)]. The thick visceral pleural peel is carefully and meticulously removed from the surface of the entire lung releasing the encased lung [Fig. V (A and B)].

As the decortication was performed early, the peel was often pliable and stripped away from lung and chest wall without major air leak or substantial blood loss.

Re-expansion of trapped areas of lung was assessed by manual ventilation [Fig. V (C and D)]. Lung re-expansion was immediate and quite gratifying in all patients. All significant air leaks are meticulously closed using absorbable sutures [Fig. VI (A and B)]. Thoracic cavity is irrigated thoroughly with normal saline.

Chest tube drain was placed, ribs approximated and thoracotomy wound closed in layer after giving an intercostals block. Fig. VII (A and B) shows specimen of removed pus and debris along with excised rib and (C and D) shows removed thickened visceral pleural peel and debris. Fig. VIII (A and B) shows children were extubated in the operating room after completion of operation.

Data Collection:

The patient’s demographics, clinical presentations, operative findings, operative time, length of hospital stay and outcomes were recorded from hospital records

Statistical  Analysis:

Descriptive statistical analysis was done and results were presented in terms of frequency and percentages.

Informed written signed consent was taken from the patient’s parent after explaining for them regarding the nature of surgery, the outcome and possible complications.

Fig. VIII (A and B) shows children were extubated in the

operating room after completion of operation.

Empyema thoracis in childhood is usually develops as a complication of post infectious pneumonia, although it can also occur following trauma, esophageal perforation or thoracic operation. Empyema thoracis ia a life threatening medical emergency. In the present study, all the presented empyema are (stage II – III) in advance stage. Standard posterolateral thoracotomy and decortication is our treatment of choice and found a safe, effective and rapid recovery from symptoms. Empyema thoracis usually presents with persistent high-grade fever, dyspnea/tachypnea, cough and chest discomfort.2,3,7 In our study we found respiratory distress is the most triggering factor for referral. Right lung involvement is more predominant and less than 7.1 % are bilateral.6 In our study, we also found similar findings where right sided empyema is more than the left sided empyema. Empyema thoracis is mostly seen in low socioeconomic status, malnutrition children, similar to other studies conducted in developing countries7,8 and still remains a significant health problem due to delay in diagnosis of pneumonia and delayed referral to higher center for adequate treatment. In our study, 80% of patients show sterile pleural pus culture and 20% bacterial growth. Staphylococcus Aureus was the most commonly isolated organism, which is comparable to other studies.10.,11 In present study, we observed that patients often presented late. The duration of symptoms has been suggested as an important factor in accurately assessing the stage of empyema. Proper estimation of the stage of the empyema has been reported to be a crucial in deciding an adequate treatment option.7,12 Some author13,14 observed that the availability of non-surgical alternative results in delayed surgical consultation, ultimately disease progress and increased patient’s morbidity and mortality. Therapeutic consideration should be based on the stage of the disease, the response to initial treatment and the degree of lung encasement.12,15 Stage I (exudative) and early stage II (fibropurulent) empyema thoracis can usually be treated by tube thoracostomy and antibiotic.2,4,16 In our study, none of the patients was seen in the exudative or early fibropurulent stage. In the late stage II (fibropurulent) and stage III (organized), prolonged tube thoracostomy drainage, is often inadequate or impossible to complete resolution where thoracotmy and decortication becomes mandatory2,3,4,7 which are similar to our study. Failure to establish an early, in developing empyema thoracis with delay in performing tube thoracostomy and ineffective antibiotic therapy allows progression of the empyema process. The lately recognized fibropurulent material organizes, the lung becomes entrapped and rendering it completely functionless. It was useful to recognize that chest x-ray may show opacity in hemithorax, loculated air and scoliosis, it tends to underestimates the extent of pleural disease and the volume of lung entrapped by the pleural peel.3,7 In our study, we found similar finding at initial presentation without tube thoracostomy. Tube thoracostomy was done all the case after diagnosis to reduce septic load 4 and serial checked chest x-rays show no sign of improvement in expansion of lung. Computed tomography of chest plays an important role in evaluating empyema thoracis, as it clearly shows the extent of pleural involvement and how much lung is encased, while also helping distinguish pleural disease from underlying lung (parenchymal ) pathology.7,17 The present study, we also found computed tomography of chest is the investigation of choice for empyema thoracis to evaluate the progress as well as stage of the empyema and especial important rule in taking immediate decisions for surgical intervention. More recent video-assisted thoracoscopic surgery shows good result in early stage I - II empyema but in late stage III empyema more conversion to open thoracotomy due to difficulty in complete removal of thick pleural peel and bleeding secondary to inflammation, making endoscopic visibility poor.7,9,12 In early stage stage 1- stage II video-assisted thoracoscopic surgery has advantages over open thoracotomy and decortication are speedy recovery and shorter hospital stay with less pain , better cosmetic, improve late functional outcome. However, with video-assisted thoracoscopic surgery, time to apyrexia, duration of chest drainage, and hospitalization stay, all appear to be more favorable after thoracotomy and decortications in the present study.19 In stage III, the role of video assisted thoracoscopic is however very much debatable.18 Postoperative pain in this present study has not been a problem with rib resection. It has been effectively controlled by epidural catheter with use of intravenous opioids and oral analgesics and for which we can able to do early drain removal and ambulation. With regard to cosmetic outcomes, although video-assisted thoracoscopic surgery is often considered superior, in most of our cases the thoracotomy incision measured only 3 to 4 cm, which is not substantially longer than the skin incision required for thoracoscopy. In the present study, priority was given to patients safety and the effectiveness of the procedure, as these factors were considered more important than cosmetic considerations. With this study, we believed that there should have a clearly prospective Randomized controlled trial study with a disease severity according to the stage of empyema thoracis as described by the American Thoracic Society to assess the merit of various treatment option available for stage II- III Empyema tharacis.20 Majority of patients in the present study, presented in late stage II – III empyema thoracis. Thoracotomy and decortication findings were staged according to the three stages of empyema thoracis development as described by the American Thoracic Society. Thoracotomy and decortication findings correlated directly with the computed tomography of chest in every instance.7,17,21 Early decortication in our study of refractory, symptomatic empyema for stage II –III, resulted in immediate and complete re-expansion of entire lung with rapid resolution of symptoms and there was no immediate late mortality.

Empyema thoracis is a progressive disease and cause significant morbidity unless treated adequately and on time. Timely and early operation provides rapid resolution of symptoms with minimal morbidity and a short hospital stay. Computed tomography of chest is an important tool for evaluation of a child with suspected empyema, especially making for surgical decision. Thoracotomy and decortication is a safe, effective, and well tolerated in children for stage II – III empyema thoracis and remains an excellent procedure of choice.