Even today, one of the most frequent complications in community-acquired pneumonia (CAP) in children is empyema thoracis (EPT), which is defined as the presence of frank pus in the pleural cavity, and it has been seen to be on the rise in some regions, despite the availability of pneumococcal vaccine [1]. It usually passes through three overlapping phases: first exudative, second fibrinopurulent with loculation and deposition of fibrin and the third, later, organizing phase when a thick visceral pleural peel impedes the re-expansion of lungs [2].

Though antibiotics and simple tube thoracostomy may be effective for early-stage parapneumonic effusions, a large number of children will have a very thick parapneumonic effusion containing fibrinopurulent or organizing material which will need more definitive intervention [3]. Open thoracotomy and decortication has been the surgical standard of care in the past and provides the opportunity to fully re-expand the lung as loculated pockets of pus are carefully evacuated and the thick peel is removed [4].

In the last 20 years, video-assisted thoracoscopic surgery (VATS) has developed as a less-invasive treatment technique which theoretically resulted in smaller incisions, less postoperative pain, shorter duration of chest tubes, and a faster recovery, with equivalent or superior control of the underlying pleural sepsis [5]. But VATS implementation is relatively lagged in paediatric surgical practice in many LMICs of which Pakistan; because of the availability of equipment, costs, and learning curve of VATS technique.

This study was conducted to directly compare the pre- and post-surgical outcomes of open versus VATS surgery in the surgical management of paediatric empyema in the tertiary care setting of Pakistan in the light of this changing landscape in surgical practice, as locally generated comparative data are also scarce, and can thus help guide surgical decisions in similar settings.

Study Design & Setting This study was a comparative observational study carried out in the Departments of Paediatric Surgery of the Tertiary Care Teaching Hospitals of Pakistan, Children's Hospital and Institute of Child Health, Lahore and National Institute of Child Health, Karachi. Data collection took place in a 6-month timeframe starting September 2025 and ending in February 2026. Ethical Approval The study was conducted after the approval of the participating hospitals' Institutional Ethical Review Committees, on the lines of Declaration of Helsinki. The legal guardians of all children enrolled gave written informed consent in accordance with their local guidelines. Inclusion Criteria ● Children from 1 to 14 years who were clinically and radiologically diagnosed with Stage II (fibrinopurulent) or Stage III (organizing) empyema thoracis. ● Children where management with antibiotics and tube thoracostomy (with or without intrapleural fibrinolytics) had failed to achieve adequate lung re-expansion. ● Children who undergo surgery as seen fit by the paediatric surgical team. Exclusion Criteria ● Children who had Stage I (simple exudative) parapneumonic effusion who were treated with tube thoracostomy alone were able to be treated successfully ● Child with severe underlying cardiac or congenital lung malformations ● When operative and/or clinical data is missing or incomplete. Surgical Technique In the Open Surgery Group, a standard posterolateral thoracotomy was performed, and under direct vision the pleural cavity was opened, the loculations were broken down and the visceral and parietal pleura were decorticated with the removal of the pus, and an intercostal chest drain was inserted. In the VATS Group, a three-port thoracoscopic approach was used to break down fibrinous loculations and do decortication under thoracoscopic visualization; then, convert to the open approach in cases with dense adhesions, uncontrolled bleeding, or inadequate lung re-expansion, which required safety-oriented treatment. Outcome Measures The main end points were operation time and length of stay in the hospital after surgery. Secondary outcomes were intraoperative blood loss, length of stay of chest tube, postoperative pain score on a Visual Analogue Scale (VAS) after 24 hours, postoperative complication rate, and conversion rate from VATS to open surgery. Statistical Analysis SPSS version 26.0 was used for the analysis of the obtained data. For continuous variables, means ± SD were used and compared via independent samples t-test. Categorical variables were expressed as frequencies and percentages; comparison was done by using chi-square test. Statistically significant p-values were determined by a 5% α.

During the six months of the study, a total of 90 children with empyema thoracis were enrolled, with 46 children being treated in the Open Surgery Group and 44 in the VATS Group. The two groups were comparable in age, gender, laterality, disease stage and organism identification as summarized in Table 1.

The VATS group had significantly shorter operative time than the open surgery group (89.5 ± 16.2 vs 98.4 ± 18.6 minutes, p = 0.038) as shown in Table 2. Intraoperative blood loss was substantially lower in the VATS group (28.6 ± 9.4 vs. 62.3 ± 15.2 mL, p < 0.001), as was chest tube duration (5.2 ± 1.6 vs. 8.6 ± 2.1 days, p < 0.001) and postoperative hospital stay (7.8 ± 2.0 vs. 12.4 ± 3.2 days, p < 0.001).

VATS patients had significantly lower 24-hour postoperative pain score (3.8 ± 1.1 vs 6.2 ± 1.4; p < 0.001) and resulted in an overall lower complication rate (13.6% vs 28.3%; p = 0.041). All the complication types are found in Figure 1 with the majority of complications being prolonged air leak and wound infection. Intra-operative conversion to open thoracotomy was necessary in four patients (9.1%) with VATS (most often because of dense pleural adhesions without any issue of poor exposure to the lung).

Table 1: Demographic and Clinical baseline characteristics (n = 90).

Table 2: shows the comparative peri/Post operative outcomes.

VATS was linked to a significantly decreased operative time and blood loss, reduced chest tube-, hospital–days, reduced post-operative pain and reduced complications associated with the procedure when compared with open surgery in the management of paediatric empyema in this comparative study. These results reflect the international literature which shows thoracoscopic methods to be more superior to open thoracotomy for paediatric pleural sepsis [7,8]. A randomised comparison of thoracoscopic decortication vs tube thoracostomy and fibrinolysis revealed a significantly shorter hospital stay and lower cost to thoracoscopic management and this has supported a more minimally invasively approach as first line surgery in appropriately selected children [9]. Likewise, a group of infants/children treated thoracoscopically with empyema also experienced a decrease in narcotic use and early return to normal activities when compared with historical open surgery controls [10]. A similar study performed in a tertiary care children's hospital in Karachi, showed similar results, as children managed by thoracoscopy had significantly shorter lengths of stay and less wound complications than those managed with open thoracotomy [11]. In another study in a paediatric surgical unit in Lahore, the same conclusion was reached that VATS had lower operational morbidity and quick recovery in paediatric patients and conversion to open surgery was observed and measured in patients with advanced organizing empyema [12] and a similar scenario was seen in the current study. The lower blood loss and less postoperative pain might be due to smaller access incisions and less trauma to the chest wall associated with thoracoscopy than with muscle-splitting or muscle-sparing thoracotomy in open decortication [8]. A decrease in chest tube placement and hospital stay in the VATS group would also likely reflect the increased efficiency of thoracoscopically directed evacuation of loculated pus when performed under optic magnification; along with a smaller physiological insult in the VATS procedure [7,10]. In this series the conversion rate in the VATS group was 9.1%, consistent with those reported in other literature [9,12] highlighting the importance of adequate patient selection and surgeon experience; children with a dense, well structured peel at a late stage of the disease may benefit from a planned open approach or early conversion if the thoracoscopic dissection is inappropriate [12]. This underlines the importance of personalised decisions for surgery and not a rigid one size fits all approach to paediatric empyema. In the context of the resource-planning, these findings have practical implications for paediatric surgical units in Pakistan who are thinking to increase the use of VATS. While the setting up cost of thoracoscopic equipment and the training of surgeons is seen as a hurdle, the potential downstream benefit of VATS in terms of less hospital stay, fewer complications, reduced nurse time and fewer antibiotic courses may result in benefits that overcome the initial investment over time, especially in a high-volume tertiary care setting. A structured training and phased equipment procurement could enable thoracoscopic management to become available for more paediatric surgical units throughout the country. This study has certain limitations. Surgical approach was not randomized and was assigned based on surgeon preference and availability of resources, which could have led to some selection bias. All studies occurred over relatively brief 6-month study periods and long-term pulmonary function or recurrence was not evaluated. More large, multi-center, ideally randomized trials with longer follow-up are advocated to further clarify the relative utility of VATS vs open surgery in all stages of paediatric empyema severity.

In paediatric empyema management, video-assisted thoracoscopic surgery is reported to have significantly better perioperative and postoperative outcomes as compared to open surgery, including a shorter operative time, less blood loss, shorter chest tube days, hospital stay, reduced postoperative pain and fewer complications. These results argue for increasing the use of VATS as the standard initial surgical treatment for children with empyema in centers with the appropriate surgical resources available and open thoracotomy should be used in cases in which the organizing disease is advanced and thoracoscopic dissection is not feasible. Sustained commitment to thoracoscopy training, facilities and equipment, along with a clear and individualised assessment of patients and prompt switching to thoracoscopy, if needed, may contribute to making thoracoscopy benefit the broadest number of children in Pakistan with empyema in tertiary care centres.

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