After that debridement and placement of pleural tubes during VATS was performed in all 11 children. Most specimens cultured were sterile, probably because of the use of oral antibiotics before the recognition of the parapneumonic effusion. Streptococcus pneumonia was isolated in one patient and Staphylococcus

aureus MSSA – methicillin susceptible – also in one patient. In every case the lung expansion was partial after VATS, despite of active suction drainage, and rehabilitation. Starting from the 2nd post-operative day, all children received fibrinolytics for 2–6 days via chest tubes. In the literature problems encountered with the use of fibrinolytics were allergic reactions and antibody Afatinib mw neutralization of the fibrinolytic agent during prolonged therapy [1] and [8]. Serious complications from fibrinolytic treatment did not occur in this series. In our series the small percentage of patients required second VATS Alectinib and one VATS was supported by mini-thoracotomy. Those patients in which combined VATS and fibrinolytic therapy had been most effective were those slightly less affected, in whom earlier and more aggressive

treatment had been initiated. The treatment of patients who have pediatric empyema by using thoracostomy tube drainage alone is reported to have primary success rate of 32–89% [8], [9], [10] and [11]. Reported average lengths of hospitalization range from 20 to 23 days [8], [9], [10] and [11]. Treatment of fibropurulent empyema in children with thoracoscopy is reported to be associated with average hospitalizations of 7–25 days, average thoracostomy tube dwell times of 3–21 days, and treatment success rates of 89%–100% [3], [8] and [12]. Among our patients VATS combined with use of fibrinolytics resulted in 100% success rate. The thoracostomy tube dwell time for our patients was 4–27 many days (mean 18.6 days),

and the hospitalization time was 7–32 days (mean 22.3 days). When the empyema is in the exudative or fibrinopurulent stage and has been present for approximately 3 weeks duration or less, thoracoscopic intervention is usually successful. When the empyema has been present for longer than 3 weeks (organizing phase) as in our patients, the ability to perform an adequate decortication may be more difficult due to denser adhesions and the presence of an adherent pulmonary visceral peel [13] and [14]. Also the lack of experience – the study was retrospectively performed on 11 patients, may be the cause of the fact that in our 3 patients the second VATS debridement was necessary. Patients with an exudative or fibrinopurulent empyema can almost always be approached with thoracoscopy. Conversion to open thoracotomy is performed when necessary and should not be considered a failure of thoracoscopy, but rather as a mature surgical judgment as in our youngest patient.