JAMA Pediatrics: Endoscopy Topic Collection

Hold Those Scalpels

Weinstein M, Cohen E. — Mon, 07 Jul 2008 00:00:00 GMT

In their well-conceived study comparing primary operative vs nonoperative management of empyema, Li and Gates analyzed administrative data from a 1-year period to eliminate historical bias and attempted to control for patient and hospital characteristics in their analysis, which found operative management to be associated with decreased length of stay (LOS) and hospital charges. We suggest that it would be misleading to conclude from their study that primary operative management (video-assisted thorascopic surgery [VATS] or open decortication) is superior to nonoperative management. The nonoperative group in their study was a heterogeneous group including children treated with antibiotics alone. One-third of the 1173 children did not undergo chest tube drainage during the initial hospitalization, and only a very small number (27 children) received intrapleural fibrinolytic therapy. From the administrative data available, one cannot ascertain the timing, drug, or dosing regimen to draw meaningful conclusions about the role of fibrinolytic therapy in the nonoperative arm. Nevertheless, the authors found no significant differences in LOS, hospital charges, or complication rates between the fibrinolytic and operative groups.

Hold Those Scalpels—Reply

Li ST, Gates RL. — Mon, 07 Jul 2008 00:00:00 GMT

In reply

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

Shah SS, DiCristina CM, Bell LM, et al. — Mon, 07 Jul 2008 00:00:00 GMT

Objective

To determine the effect of initial procedure type on the length of hospital stay (LOS) and on the requirement for additional pleural fluid drainage procedures in a large multicenter cohort of children with pneumonia complicated by pleural effusion.

Design

Retrospective cohort study.

Setting

Administrative database containing inpatient resource use data from 27 tertiary care children's hospitals.

Participants

Patients between 12 months and 18 years of age diagnosed as having complicated pneumonia were eligible for the study if they were discharged from the hospital between January 1, 2001, and December 31, 2005, and underwent early (within 2 days of the index hospitalization) pleural fluid drainage.

Intervention

Pleural fluid drainage, categorized as chest tube placement, video-assisted thoracoscopic surgery (VATS), or thoracotomy.

Main Outcome Measures

The LOS and the requirement for additional pleural fluid drainage.

Results

Nine hundred sixty-one of 2862 patients (33.6%) with complicated pneumonia underwent early pleural fluid drainage. Initial procedures included chest tube placement (n = 714), VATS (n = 50), and thoracotomy (n = 197). The median patient age was 4.0 years (interquartile range, 2.0-8.0 years). The median LOS was 10 days (interquartile range, 7-14 days). Two hundred ninety-eight patients (31.0%) required at least 1 additional pleural fluid drainage procedure, and 44 patients (4.6%) required more than 2 pleural fluid drainage procedures. In linear regression analysis, children undergoing primary VATS had a 24% (adjusted β coefficient, −0.24; 95% confidence interval, −0.41 to −0.07) shorter LOS than patients undergoing primary chest tube placement; this translated into a 2.8-day reduction in the LOS for those undergoing early primary VATS. In logistic regression analysis, patients undergoing primary VATS had an 84% (adjusted odds ratio, 0.16; 95% confidence interval, 0.06-0.42) reduction in the requirement for additional pleural fluid drainage procedures compared with patients undergoing primary chest tube placement.

Conclusion

Our large retrospective multicenter study demonstrates that, compared with primary chest tube placement, primary VATS is associated with shorter LOS and fewer additional procedural interventions.