Overview
Definition:
Pediatric thoracoscopy with decortication is a minimally invasive surgical procedure performed to remove thickened, constricting pleura (peel or peel-like membrane) from the lung surface in children
This is most commonly indicated for chronic or organized pleural infections (empyema) where the pus has become loculated and the lung is compressed, preventing full re-expansion
It allows for better lung function and resolution of infection.
Epidemiology:
Empyema thoracis is a significant cause of pediatric morbidity and mortality, with an incidence of approximately 1-2 cases per 10,000 children annually
Bacterial pneumonia is the most common preceding illness, with Streptococcus pneumoniae being the most frequent pathogen
Staphylococcus aureus and group A Streptococcus are also common culprits
Risk factors include prematurity, immunocompromise, and delayed or inadequate antibiotic therapy.
Clinical Significance:
Untreated or inadequately treated empyema can lead to significant long-term pulmonary sequelae, including restrictive lung disease, chronic cough, and reduced exercise tolerance
Decortication, particularly when performed thoracoscopically, offers the advantage of less pain, shorter hospital stays, and quicker recovery compared to open thoracotomy
It is crucial for residents to understand the indications, technique, and management of this condition for effective patient care and successful examination performance in DNB and NEET SS.
Indications
Indications For Decortication:
Failure of initial medical management (antibiotics, drainage) for empyema
Persistent fever or sepsis despite appropriate treatment
Presence of loculated pleural fluid or thick, organized peel on imaging (CT scan)
Significant lung compression and incomplete lung expansion on imaging
Chronicity of empyema (typically > 4-7 days without improvement).
Contraindications:
Absolute contraindications are rare but include severe coagulopathy, uncorrectable hemodynamic instability, or complete lung collapse with irreversible lung parenchymal damage
Relative contraindications include extreme prematurity, severe comorbidities, and extensive pleural symphysis making access difficult.
Timing Of Intervention:
Early intervention is generally preferred, ideally when the empyema is organized but before extensive pleural fibrosis occurs
Thoracoscopic decortication is often feasible between 7-21 days after the onset of empyema, but the decision is based on the radiological appearance and clinical status of the patient.
Diagnostic Approach
History Taking:
Detailed history of preceding illness (pneumonia, fever, cough)
Duration and character of symptoms (dyspnea, chest pain, constitutional symptoms)
Previous treatments, including antibiotics and drainage procedures
History of immunocompromise or other chronic conditions
Red flags include high fever, tachypnea, decreased breath sounds, and signs of sepsis.
Physical Examination:
General appearance (distress, hydration)
Vital signs (temperature, heart rate, respiratory rate, oxygen saturation)
Chest examination for asymmetry, decreased chest expansion, dullness to percussion, and diminished or absent breath sounds
Palpation for tenderness or effusion.
Investigations:
Chest X-ray (PA and lateral): may show pleural effusion, opacification, and loculations
CT scan of the chest with intravenous contrast: essential for defining the extent of the effusion, loculations, and the thickness of the pleural peel
helps in planning surgical approach
Ultrasound of the chest: useful for initial assessment of effusion and guiding diagnostic thoracentesis
Pleural fluid analysis: pH, glucose, protein, LDH, cell count, Gram stain, culture, and sensitivity
crucial for identifying the causative organism and guiding antibiotic therapy
Blood tests: Complete blood count (leukocytosis, neutrophilia), C-reactive protein (CRP), procalcitonin, blood cultures, and electrolytes.
Surgical Management
Preoperative Preparation:
Optimizing the patient's clinical status
Initiation of appropriate intravenous antibiotics based on culture results or clinical suspicion
Chest physiotherapy and pulmonary toilet
Informed consent from guardians, discussing risks, benefits, and alternatives
Pre-operative imaging review to plan port placement.
Thoracoscopic Procedure Steps:
General anesthesia with double-lumen endotracheal tube or endobronchial blocker for lung isolation
Placement of 1-3 small ports (typically 5-12 mm) in the intercostal spaces
Insertion of thoracoscope and instruments
Identification of the pleural peel and the compressed lung
Careful dissection of the peel from the visceral and parietal pleura, starting from the most accessible areas (e.g., diaphragm, posterior chest wall)
Release of adhesions and removal of organized pus and fibrinous exudates
Lung re-expansion is assessed
Placement of one or two chest tubes for drainage
Mechanical pleurodesis may be performed if indicated
Intraoperative irrigation and hemostasis.
Instrumentation:
Thoracoscope (rigid or flexible), light source, camera system
Various graspers, dissectors, scissors, and suction devices
Chest tubes of appropriate size
Harmonic scalpel or electrocautery for dissection may be used judiciously
Suction-irrigation system.
Postoperative Care
Pain Management:
Multimodal analgesia including intravenous or oral opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and sometimes paravertebral or intercostal nerve blocks
Adequate pain control is crucial for early mobilization and pulmonary rehabilitation.
Chest Tube Management:
Chest tubes are typically connected to an underwater seal drainage system, often with suction
Monitoring of drainage volume, character, and air leak
Chest tubes are usually removed when drainage is minimal (< 5-10 mL/kg/day or < 100 mL/day) and no air leak is present, and the lung is fully expanded.
Respiratory Support:
Encourage deep breathing exercises, incentive spirometry, and early ambulation
Humidified oxygen therapy as needed
Monitor respiratory rate, oxygen saturation, and breath sounds
Chest physiotherapy may be continued.
Antibiotic Therapy:
Continuation of intravenous antibiotics, tailored to culture and sensitivity results, for a total duration of typically 10-14 days or longer, depending on the clinical response and extent of infection
Oral antibiotics may be used for a subsequent period if necessary.
Complications
Early Complications:
Bleeding (intraoperative or postoperative)
Air leak from the lung or chest wall
Persistent fever or failure to resolve infection
Injury to adjacent structures (lung parenchyma, intercostal vessels/nerves)
Retained hemothorax or re-accumulation of pus
Anesthesia-related complications.
Late Complications:
Chronic empyema
Pleural thickening and fibrosis leading to restrictive lung disease
Persistent pain
Recurrence of empyema
Bronchopleural fistula (rare).
Prevention Strategies:
Judicious use of instruments to avoid lung injury
Meticulous hemostasis
Ensuring adequate drainage and seal with chest tubes
Prompt identification and management of air leaks
Aggressive chest physiotherapy and early mobilization
Appropriate duration and spectrum of antibiotic therapy.
Prognosis
Factors Affecting Prognosis:
Timeliness of diagnosis and intervention
Severity and chronicity of the empyema
Causative organism
Presence of comorbidities
Extent of lung parenchymal involvement
Skill of the surgical team
Adherence to postoperative care protocols.
Outcomes:
Most children undergoing thoracoscopic decortication have a good prognosis with complete resolution of infection and return to normal lung function
Long-term outcomes are generally better with minimally invasive techniques compared to open procedures
However, some may experience residual pleural thickening or mild restrictive physiology.
Follow Up:
Regular follow-up visits including clinical examination and serial chest X-rays or CT scans to monitor for recurrence, lung expansion, and development of late complications like pleural thickening or fibrosis
Pulmonary function tests may be considered in select cases if symptoms of restrictive disease persist.
Key Points
Exam Focus:
Thoracoscopic decortication is the gold standard for managing organized pediatric empyema
Key steps include port placement, peel dissection, and lung re-expansion
Complications like bleeding and air leak are common but manageable
CT scan is crucial for pre-operative planning.
Clinical Pearls:
Early identification and intervention for empyema improve outcomes
Always consider S
aureus and S
pyogenes in pediatric empyema
Thoracoscopic approach minimizes morbidity
Thorough dissection of all peel is essential for complete lung expansion.
Common Mistakes:
Delaying surgical intervention in organized empyema
Inadequate dissection of the pleural peel
Failure to identify and manage air leaks
Insufficient duration or incorrect choice of antibiotics
Over-reliance on chest tube drainage alone for organized empyema.