Journal of pediatric surgery · 2025
New insights into the management of complicated pneumonia in children: A systematic review of randomized controlled trials.
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Tzoni Georgia, Dimopoulou Anastasia, Dimopoulou Dimitra
Аннотация
BACKGROUND: Complicated parapneumonic effusions and empyema are serious complications of pneumonia in children and often require invasive management. The optimal treatment-surgical versus non-surgical-remains controversial.
OBJECTIVES: To compare the clinical effectiveness and safety of surgical versus non-surgical treatment approaches for complicated parapneumonic effusions and empyemas in children, based on evidence from randomized controlled trials (RCTs).
METHODS: We systematically reviewed RCTs comparing surgical interventions (VATS, thoracotomy) to conservative management (chest tube drainage with or without fibrinolytics) in children with complicated parapneumonic effusion or empyema. PubMed, Scopus, and Web of Science were searched up to July 2025. Primary outcomes included hospital stay, time to recovery, and duration of drainage. Risk of bias was assessed using the Cochrane RoB 2.0 tool. A narrative synthesis was performed.
RESULTS: Eighteen RCTs involving a total of 937 participants were included. Non-surgical approaches using fibrinolytics (urokinase, streptokinase, tPA) were clinically equivalent to surgery regarding the majority of outcomes, including length of hospital stay and treatment success. Some trials showed faster radiological resolution with VATS, but no consistent superiority. Conservative management was frequently associated with lower costs and fewer procedure-related complications. Risk of bias was generally low to moderate.
CONCLUSION: Non-surgical management with intrapleural fibrinolytics is a safe and effective alternative to surgery for pediatric empyema. Given the comparable clinical outcomes and reduced invasiveness, conservative treatment should be considered as the first-line management in most cases. Additional trials are needed to identify patient subgroups who may benefit from early surgical intervention.
OBJECTIVES: To compare the clinical effectiveness and safety of surgical versus non-surgical treatment approaches for complicated parapneumonic effusions and empyemas in children, based on evidence from randomized controlled trials (RCTs).
METHODS: We systematically reviewed RCTs comparing surgical interventions (VATS, thoracotomy) to conservative management (chest tube drainage with or without fibrinolytics) in children with complicated parapneumonic effusion or empyema. PubMed, Scopus, and Web of Science were searched up to July 2025. Primary outcomes included hospital stay, time to recovery, and duration of drainage. Risk of bias was assessed using the Cochrane RoB 2.0 tool. A narrative synthesis was performed.
RESULTS: Eighteen RCTs involving a total of 937 participants were included. Non-surgical approaches using fibrinolytics (urokinase, streptokinase, tPA) were clinically equivalent to surgery regarding the majority of outcomes, including length of hospital stay and treatment success. Some trials showed faster radiological resolution with VATS, but no consistent superiority. Conservative management was frequently associated with lower costs and fewer procedure-related complications. Risk of bias was generally low to moderate.
CONCLUSION: Non-surgical management with intrapleural fibrinolytics is a safe and effective alternative to surgery for pediatric empyema. Given the comparable clinical outcomes and reduced invasiveness, conservative treatment should be considered as the first-line management in most cases. Additional trials are needed to identify patient subgroups who may benefit from early surgical intervention.