Surgery for Pediatric Pleural Effusions No Better Than Conservative Treatment

SAN FRANCISCO – Conservative treatment may be best for pneumonia-related pleural effusions in children, according to a retrospective review from Washington University in St. Louis.

Median hospital costs were significantly lower ($11,149 vs. $28,552; P less than .001) and there was a nonsignificant trend toward shorter median hospital stays (6 vs. 8 days) for 17 children with moderate-large pleural effusions treated at St. Louis Children’s Hospital with intravenous antibiotics or tube drainage from 2007 to 2010 compared with 81 treated more aggressively with thoracotomy and decortication or video-assisted thoracoscopic surgery (VATS), which has become first-line treatment at the hospital and many other medical centers.

It’s not that the children treated aggressively were sicker, said lead investigator Dr. Piyaporn Chuen-Im, a third-year fellow in pediatric pulmonology.

"In terms of fever, white count, acuity" and other measures, "there were really no [statistically significant] differences between the two groups." That some children were managed medically and others surgically illustrates the "inconsistencies in how plural effusions are treated" in children in St. Louis and elsewhere, she said.

Overall, "the trend is to treat more aggressively" but it might not be necessary, at least in some cases, she said. Surgery "did not offer significant benefits" in the study; children "might have better outcomes and maybe lower hospital charges" with a gentler approach, Dr. Chuen-Im said.

The investigators also looked at records for children treated from 2000 to 2006, although in less depth than for children treated later; the review involved 338 children ranging in age from 1 month to 20 years.

VATS was used for less than 10% of moderate-large pediatric pleural effusions in the early part of the decade, but about 75% in 2009.

Some studies have found better effusion outcomes with VATS in children, leading to its adoption as first-line treatment. Other studies suggest it should be kept in reserve for failed medical treatment (Thorax 2005;60:94-6).

What’s needed is "a big, prospective, randomized, controlled trial to determine the benefits of surgical intervention as first-line therapy," Dr. Chuen-Im said.

Assessment and treatment need to be standardized as well, perhaps according to radiologic parameters, presence of loculation on ultrasound, fluid make-up, or other factors, she said.

Effusion size alone is not enough to guide treatment. Children managed aggressively in the study did tend to have larger effusions, but "we did not find that the size predicted whether the fluid is complicated," indicating more severe disease. "That’s why I’m not sure [basing intervention] on size is a good idea," Dr. Chuen-Im said.

Also, radiologists who reviewed imaging for the study "had considerable disagreement in terms of the assessment of size," a problem because "many people tend to rely on [radiologist] assessment for management." If nothing else, "standardized radiographic measures to consistently define the size of pleural effusions are needed" for children, she said.

Treatment inconstancies are a problem "across the board, not just at this hospital, and even across single institutions. We all deal with this," said Dr. Cori Daines, a pediatric pulmonologist the University of Arizona in Tucson, commenting on the study.

"As a clinician, I rely on my radiologist to give me information to decide [if] I need to call my surgeon. [When] I am getting different opinions from radiologists based on their own tests, that’s concerning." Meanwhile, "we are [also] seeing way more of our pleural effusions going to VATS and surgical intervention," she said.

Dr. Daines, Dr. Chuen-Im, and coinvestigators said they have no relevant disclosures.

SAN FRANCISCO – Conservative treatment may be best for pneumonia-related pleural effusions in children, according to a retrospective review from Washington University in St. Louis.

Median hospital costs were significantly lower ($11,149 vs. $28,552; P less than .001) and there was a nonsignificant trend toward shorter median hospital stays (6 vs. 8 days) for 17 children with moderate-large pleural effusions treated at St. Louis Children’s Hospital with intravenous antibiotics or tube drainage from 2007 to 2010 compared with 81 treated more aggressively with thoracotomy and decortication or video-assisted thoracoscopic surgery (VATS), which has become first-line treatment at the hospital and many other medical centers.

It’s not that the children treated aggressively were sicker, said lead investigator Dr. Piyaporn Chuen-Im, a third-year fellow in pediatric pulmonology.

"In terms of fever, white count, acuity" and other measures, "there were really no [statistically significant] differences between the two groups." That some children were managed medically and others surgically illustrates the "inconsistencies in how plural effusions are treated" in children in St. Louis and elsewhere, she said.

Overall, "the trend is to treat more aggressively" but it might not be necessary, at least in some cases, she said. Surgery "did not offer significant benefits" in the study; children "might have better outcomes and maybe lower hospital charges" with a gentler approach, Dr. Chuen-Im said.

The investigators also looked at records for children treated from 2000 to 2006, although in less depth than for children treated later; the review involved 338 children ranging in age from 1 month to 20 years.

VATS was used for less than 10% of moderate-large pediatric pleural effusions in the early part of the decade, but about 75% in 2009.

Some studies have found better effusion outcomes with VATS in children, leading to its adoption as first-line treatment. Other studies suggest it should be kept in reserve for failed medical treatment (Thorax 2005;60:94-6).

What’s needed is "a big, prospective, randomized, controlled trial to determine the benefits of surgical intervention as first-line therapy," Dr. Chuen-Im said.

Assessment and treatment need to be standardized as well, perhaps according to radiologic parameters, presence of loculation on ultrasound, fluid make-up, or other factors, she said.

Effusion size alone is not enough to guide treatment. Children managed aggressively in the study did tend to have larger effusions, but "we did not find that the size predicted whether the fluid is complicated," indicating more severe disease. "That’s why I’m not sure [basing intervention] on size is a good idea," Dr. Chuen-Im said.

Also, radiologists who reviewed imaging for the study "had considerable disagreement in terms of the assessment of size," a problem because "many people tend to rely on [radiologist] assessment for management." If nothing else, "standardized radiographic measures to consistently define the size of pleural effusions are needed" for children, she said.

Treatment inconstancies are a problem "across the board, not just at this hospital, and even across single institutions. We all deal with this," said Dr. Cori Daines, a pediatric pulmonologist the University of Arizona in Tucson, commenting on the study.

"As a clinician, I rely on my radiologist to give me information to decide [if] I need to call my surgeon. [When] I am getting different opinions from radiologists based on their own tests, that’s concerning." Meanwhile, "we are [also] seeing way more of our pleural effusions going to VATS and surgical intervention," she said.

Dr. Daines, Dr. Chuen-Im, and coinvestigators said they have no relevant disclosures.

SAN FRANCISCO – Conservative treatment may be best for pneumonia-related pleural effusions in children, according to a retrospective review from Washington University in St. Louis.

Median hospital costs were significantly lower ($11,149 vs. $28,552; P less than .001) and there was a nonsignificant trend toward shorter median hospital stays (6 vs. 8 days) for 17 children with moderate-large pleural effusions treated at St. Louis Children’s Hospital with intravenous antibiotics or tube drainage from 2007 to 2010 compared with 81 treated more aggressively with thoracotomy and decortication or video-assisted thoracoscopic surgery (VATS), which has become first-line treatment at the hospital and many other medical centers.

It’s not that the children treated aggressively were sicker, said lead investigator Dr. Piyaporn Chuen-Im, a third-year fellow in pediatric pulmonology.

"In terms of fever, white count, acuity" and other measures, "there were really no [statistically significant] differences between the two groups." That some children were managed medically and others surgically illustrates the "inconsistencies in how plural effusions are treated" in children in St. Louis and elsewhere, she said.

Overall, "the trend is to treat more aggressively" but it might not be necessary, at least in some cases, she said. Surgery "did not offer significant benefits" in the study; children "might have better outcomes and maybe lower hospital charges" with a gentler approach, Dr. Chuen-Im said.

The investigators also looked at records for children treated from 2000 to 2006, although in less depth than for children treated later; the review involved 338 children ranging in age from 1 month to 20 years.

VATS was used for less than 10% of moderate-large pediatric pleural effusions in the early part of the decade, but about 75% in 2009.

Some studies have found better effusion outcomes with VATS in children, leading to its adoption as first-line treatment. Other studies suggest it should be kept in reserve for failed medical treatment (Thorax 2005;60:94-6).

What’s needed is "a big, prospective, randomized, controlled trial to determine the benefits of surgical intervention as first-line therapy," Dr. Chuen-Im said.

Assessment and treatment need to be standardized as well, perhaps according to radiologic parameters, presence of loculation on ultrasound, fluid make-up, or other factors, she said.

Effusion size alone is not enough to guide treatment. Children managed aggressively in the study did tend to have larger effusions, but "we did not find that the size predicted whether the fluid is complicated," indicating more severe disease. "That’s why I’m not sure [basing intervention] on size is a good idea," Dr. Chuen-Im said.

Also, radiologists who reviewed imaging for the study "had considerable disagreement in terms of the assessment of size," a problem because "many people tend to rely on [radiologist] assessment for management." If nothing else, "standardized radiographic measures to consistently define the size of pleural effusions are needed" for children, she said.

Treatment inconstancies are a problem "across the board, not just at this hospital, and even across single institutions. We all deal with this," said Dr. Cori Daines, a pediatric pulmonologist the University of Arizona in Tucson, commenting on the study.

"As a clinician, I rely on my radiologist to give me information to decide [if] I need to call my surgeon. [When] I am getting different opinions from radiologists based on their own tests, that’s concerning." Meanwhile, "we are [also] seeing way more of our pleural effusions going to VATS and surgical intervention," she said.

Dr. Daines, Dr. Chuen-Im, and coinvestigators said they have no relevant disclosures.