A randomized trial of empyema therapy

Study objectives: To determine the optimal treatment of empyema thoracis (within the fibrinopurulent phase of illness) comparing pleural drainage and fibrinolytic therapy vs video-assisted thoracoscopic surgery (VATS), with regard to efficacy and duration of hospitalization. Design: Twenty patients with confirmed parapneumonic empyema thoracis were randomized to chest tube pleural drainage plus streptokinase (CT-SK) vs VATS, Setting: University-based teaching hospital providing for Dallas County. Patients and methods: Equivalent groups of patients with parapneumonic empyema thoracis were randomized to receive either of two therapies: CT-SK (n = 9) or VATS (n = 11), Outcomes analysis with respect to treatment efficacy, hospital duration, chest tube duration, hospital costs, and need for subsequent procedures was performed. Results: Each group suffered one mortality (p = not significant), When compared with the CT-SE group, the VATS group had a significantly higher primary treatment success [10/11, 91% vs 4/9, 44%; p < 0.05 Fisher's Exact Test], lower chest tube duration (5.8 +/- 1.1 vs 9.8 +/- 1.3 clays; p = 0.03), and lower number of total hospital days (8.7 +/- 0.9 vs 12.8 +/- 1.1 days; p = 0.009), Clinically relevant but not statistically significant differences in hospital costs ($16,642 +/- 2,841 vs $24,052 +/- 3,466, p = 0.11) also favored the VATS group. Of note, all the CT-SK treatment failures could be salvaged with VATS, and none required thoracotomy. Conclusions: In patients with loculated, complex fibrinopurulent parapneumonic empyema thoracis, a primary treatment strategy of VATS is associated with a higher efficacy, shorter hospital duration, and less cost than a treatment strategy that utilizes catheter-directed fibrinolytic therapy.