Aziz Abdulhameed, Healey Jeffrey M, Qureshi Faisal, Kane Timothy D, Kurland Geoffrey, Green Michael, Hackam David J
Division of Pediatric Surgery, Children's Hospital of Pittsburgh and the University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA.
Surg Infect (Larchmt). 2008 Jun;9(3):317-23. doi: 10.1089/sur.2007.025.
Controversy exists regarding the optimal management strategy for children having empyema or parapneumonic effusion as a complication of pneumonia. We hypothesized that video-assisted thoracoscopic surgery (VATS)-assisted drainage of pleural fluid and debridement of the pleural space is superior to a chest tube alone in the management of these patients. We further identified predictive factors-namely, presentation, radiographic findings, antibiotic usage, and pleural fluid features-that could predict the need for VATS rather than primary chest tube drainage.
Forty-nine pediatric patients with pneumonia complicated by parapneumonic effusion or empyema treated at the Children's Hospital of Pittsburgh (1997-2003) were divided into three groups according to the therapy instituted: Primary chest tube, chest tube followed by VATS, or primary VATS. The groups were analyzed in terms of demographics and outcome, as judged by pleural fluid analysis and hospital resource utilization. Demographic and outcome data were compared among groups using one-way analysis of variance and the Student t-test.
All groups were similar with respect to demographics and initial antibiotic usage. Patients undergoing primary VATS had a higher initial temperature, whereas radiographic findings of mediastinal shift and air bronchograms were more likely to be found in patients who underwent primary chest tube placement. Patients undergoing primary VATS demonstrated a significantly shorter total stay and lower hospital charges than the other groups. Forty percent of children started on chest tube therapy failed even with subsequent VATS, necessitating a significantly longer hospital course (18 +/- 3 vs. 11 +/- 0.8 days; p < 0.05) and higher hospital charges ($50,000 +/- 7,000 vs. $29,000 +/- 1000) than those having primary VATS.
Patients treated by primary VATS had a shorter stay and lower hospital charges than patients treated by chest tube and antibiotic therapy alone. There were no demographic, physiologic, laboratory, or chest radiographic data that predicted the selection of VATS as an initial treatment. These data suggest a strategy of primary VATS as first-line treatment in the management of empyema or parapneumonic effusion as a complication of pneumonia in pediatric patients.
对于肺炎并发症为脓胸或肺炎旁胸腔积液的儿童，最佳治疗策略存在争议。我们假设在这些患者的治疗中，电视辅助胸腔镜手术（VATS）辅助胸腔积液引流及胸膜腔清创术优于单纯放置胸管。我们进一步确定了一些预测因素，即临床表现、影像学表现、抗生素使用情况及胸腔积液特征，这些因素可预测是否需要VATS而非初始胸管引流。
匹兹堡儿童医院（1997 - 2003年）收治的49例肺炎合并肺炎旁胸腔积液或脓胸的儿科患者，根据所采用的治疗方法分为三组：初始胸管组、胸管后行VATS组或初始VATS组。根据胸腔积液分析和医院资源利用情况判断人口统计学和结局，对三组进行分析。使用单因素方差分析和学生t检验比较组间的人口统计学和结局数据。
所有组在人口统计学和初始抗生素使用方面相似。接受初始VATS的患者初始体温较高，而纵隔移位和气支气管造影的影像学表现更常见于接受初始胸管置入的患者。接受初始VATS的患者总住院时间明显短于其他组，住院费用也更低。40%开始接受胸管治疗的儿童即使随后接受VATS仍治疗失败，与接受初始VATS的儿童相比，其住院病程显著更长（18±3天对11±0.8天；p<0.05），住院费用更高（50,000±7,000美元对29,000±1,000美元）。
与单纯接受胸管和抗生素治疗的患者相比，接受初始VATS治疗患者的住院时间更短，住院费用更低。没有人口统计学、生理学、实验室或胸部影像学数据可预测选择VATS作为初始治疗方法。这些数据表明，对于儿科患者肺炎并发症为脓胸或肺炎旁胸腔积液的治疗，初始VATS策略可作为一线治疗方法。
