In their well-conceived study comparing primary operative vs nonoperative management of empyema, Li and Gates1 analyzed administrative data from a 1-year period to eliminate historical bias and attempted to control for patient and hospital characteristics in their analysis, which found operative management to be associated with decreased length of stay (LOS) and hospital charges. We suggest that it would be misleading to conclude from their study that primary operative management (video-assisted thorascopic surgery [VATS] or open decortication) is superior to nonoperative management. The nonoperative group in their study was a heterogeneous group including children treated with antibiotics alone. One-third of the 1173 children did not undergo chest tube drainage during the initial hospitalization, and only a very small number (27 children) received intrapleural fibrinolytic therapy.1 From the administrative data available, one cannot ascertain the timing, drug, or dosing regimen to draw meaningful conclusions about the role of fibrinolytic therapy in the nonoperative arm. Nevertheless, the authors found no significant differences in LOS, hospital charges, or complication rates between the fibrinolytic and operative groups.
Weinstein M, Cohen E. Hold Those Scalpels. Arch Pediatr Adolesc Med. 2008;162(7):698. doi:10.1001/archpedi.162.7.698-a