Simplified Thoracic Extra-Pleural (STEP) Approach for Open Decortication in Late Stages of Pediatric Empyema Thoracis: A Technical Note

Open decortication (OD) is indicated in stage III (organized stage) of pediatric empyema thoracis (PET). Conventional open decortication (COD) has a sketchy description in the literature and variable results. We adopted extrapleural approach, previously described for radical pleurectomy in mesothelioma, and describe Simplified Thoracic Extra-Pleural (STEP) approach as a step-wise technique for OD and compared with the COD. This retrospective study was conducted from January 2012 to December 2019 in a tertiary care center in Central India. All children (< 18 years) with organized stage of PET (according to Jabalpur image-based staging algorithm), conversion of video-assisted thoracoscopic surgery (VATS), and failed VATS were included. STEP decortication followed a step-wise approach of decortication and identification of safety boundaries. Outcomes were compared in terms of blood loss and transfusion, operative duration, hospital stay, complications, and readmission. Statistical analysis was performed using the Statistical Package for Social Sciences program, version 16.0. Ninety-three cases were divided into two groups based on approaches adopted by two surgeons in the unit, COD (47) and STEP (46). Male:female ratio was 55:38, with a median age of 4 years (IQR, 2-5). The two groups were demographically similar. The operative duration, blood loss, need for postoperative blood transfusion, prolonged air leak > 7 days, ICTD days, and hospital stay were significantly (p < 0.05) lower in the STEP group. The wound infection, recurrent collections, and readmission were similar in both groups. There was no mortality in either group. The STEP approach is a simple, useful, safe, and effective procedure as compared to OD. The step-wise description of the STEP approach can act as a surgical guide for surgical novice and trainees.