Pediatric Empyema Thoracis: A Comparative Study of Intercostal Drain Insertion versus Primary Video-assisted Thoracoscopic Surgery

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A BSTRACT Background: The comparative efficacy of intercostal drain (ICD) insertion versus primary video-assisted thoracoscopic surgery (VATS) for early-stage pediatric empyema is not firmly established. This study evaluates the clinical outcomes and efficiency of primary VATS compared to ICD placement in pediatric patients Stage I and Stage II empyema thoracis. Methods: This prospective comparative study was conducted from March 2024 to December 2025 at the tertiary care institute, which included 42 children (aged 1 month to 18 years). Participants were equally allocated to either the ICD group ( n = 21) or the primary VATS group ( n = 21). Primary outcomes included hospital and intensive care unit (ICU) stay duration, chest tube duration, complication rates, and cost analysis. Pain was assessed using the Face, Legs, Activity, Cry, and Consolability scale at 24 and 48 h. Results: Baseline characteristics were comparable. The primary VATS group showed a significant 32% reduction in overall hospital stay (9.19 ± 3.33 vs. 13.57 ± 4.57 days; P = 0.001) and shorter ICU stays (3.05 ± 1.12 vs. 4.90 ± 1.76 days; P < 0.001). Chest tube duration was markedly lower in the primary VATS group (6.62 ± 2.78 vs. 11.23 ± 4.37 days; P < 0.001). VATS eliminated the need for re-interventions (0% vs. 23.8%; P = 0.048) and was more cost-effective (₹49,128.5 ± 13,463.0 vs. ₹71,571.4 ± 29,611.4; P < 0.05). Patients in the VATS cohort reported slightly higher 24-h pain ( P = 0.029), but scores equalized by 48 h. Follow-up at the 2 nd and 4 th weeks postdischarge showed no complications or mortality in either group. Conclusion: Primary VATS is the preferred first-line treatment for Stage II empyema over ICD, providing better clinical outcomes, faster recovery, fewer complications, and enhanced cost-effectiveness.