6616 Is chest drain insertion and firinolysis therapy equivalent to video-assisted thoracoscopic surgery to treat children with parapneumonic effusions?

Objectives To review best available evidence to ascertain any differences to length-of-stay or second intervention rate for children with empyema treated with primary VATS vs CDF. Methods Database search using relevant keywords was carried out, and publications were screened by two independent reviewers using pre-defined inclusion and exclusion criteria. A Cochrane review and a systematic review published in 2019 were identified. The systematic review¹ included the same RCTs considered in the Cochrane review, along with an additional RCT and 5 additional cohort studies. Primary data published following the end of the systematic review authors' search were used to complement evidence from their analysis. Data were extracted and analysed by two independent reviewers. Results Keyword search yielded 62 unique results. Independent screening included 20 studies for review. Of these 20 studies, 4 were identified for inclusion, including the recent systematic review and subsequently published primary data. In the systematic review, there was a predominance of VATS patients compared with CDF, in contrast to a recent included retrospective study which showed that 95% of empyemas in the USA were treated with CDF² which could represent a reporting bias. This paper showed a significant reduction in length of stay in patients receiving primary VATS compared with CDF. Two of the studies published after the systematic review³ ⁴ found a trend towards shorter admissions, but this was not statistically significant. The final study² showed that patients receiving VATS had an overall shorter hospital length of stay. For second intervention rates, the systematic review¹ found a statistically significant difference in favour of VATS. The other studies³ ⁴ also reported this outcome, but did not show statistically significant differences. There was heterogeneity between studies in the systematic review,¹ with certain trials including children with grade II and III empymas only, and others including all grades of severity, making direct comparison of outcomes challenging. Studies included in the systematic review also used different definitions of length of stay. The most recent study included in this review² adjusted data to account for disease severity for PICU stay, but did not adjust for total hospital stay, meaning there could be baseline differences between CDF and VATS groups. Conclusion VATS and CDF appear equivalent for primary treatment in children with parapneumonic effusions requiring drainage in terms of length of hospital stay. VATS may be associated with less frequent second interventions than CDF. References Pacilli M, Nataraja RM. Management of paediatric empyema by video-assisted thoracoscopic surgery versus chest drain with firinolysis: systematic review and meta- analysis. Paediatr Respir Rev 2019;30:42–8. Derderian SC, Meier M, Partrick DA, et al. Pediatric empyemas – has the pendulum swung too far? J Pediatr Surg 2020;55:2356–61. Shankar G, Sahadev R, Santhanakrishnan R. Pediatric empyema thoracis management: should the consensus be different for the developing countries? J Pediatr Surg 2020;55:513–7. Ibarra Rodríguez MR, et al. Fibrinolysis versus thoracoscopy: comparison of results in empyema management in the child. Ann Thorac Med 2022;17:145–50.