VATS Tops Chest Tubes in Pediatric Empyema Review, but Evidence Stays Weak

A large systematic review comparing the four main treatments for empyema thoracis in children has found that video-assisted thoracoscopic surgery, or VATS, was associated with fewer treatment escalations and shorter treatment durations than chest tube drainage alone, though the authors caution that most of the underlying evidence is observational and of low certainty. Clinicians can manage it with a chest tube alone, a chest tube plus fibrinolytic drugs that dissolve the fluid, VATS, or open thoracotomy. Which strategy works best has remained uncertain, prompting researchers from Mohammed Bin Rashid University of Medicine and Health Sciences and Mediclinic Parkview Hospital in Dubai to conduct the review, which was prospectively registered with PROSPERO.

The team searched PubMed, Embase, Scopus, Web of Science and the CENTRAL database for studies published from January 2000 through January 2026 involving children under 18 years of age. They identified 77 studies covering 7,378 children. Using random-effects pairwise and frequentist network meta-analyses, they compared chest tube alone, chest tube with fibrinolytics, VATS and thoracotomy across several outcomes.

The primary outcome was hospital length of stay. Secondary outcomes included treatment escalation, treatment success, complications, mortality and treatment-related durations. Treatments were ranked using P-scores, and a sensitivity analysis restricted the network to arms in which the intervention was given as the first-line treatment.

Risk of bias was assessed with ROBINS-I, RoB 2 or the JBI checklist depending on study design, and certainty was graded with the GRADE framework. Compared with a chest tube alone, treatment escalation was lower with VATS, with a relative risk of 0.17 (95% confidence interval 0.07 to 0.37), lower with thoracotomy (RR 0.13, 95% CI 0.04 to 0.36), and lower with chest tube plus fibrinolytics (RR 0.48, 95% CI 0.26 to 0.89). Certainty was moderate for three of the six escalation comparisons and low or very low elsewhere.

VATS was also associated with shorter pleural drainage, by a mean difference of 2.54 days (95% CI 4.64 to 0.44 days fewer), shorter antibiotic duration by 4.95 days (95% CI 9.36 to 0.54 days fewer), and shorter fever duration by 2.00 days (95% CI 3.97 to 0.04 days fewer). Notably, VATS did not significantly shorten overall hospital length of stay, with a mean difference of 2.06 days (95% CI 4.57 fewer to 0.45 more). In the pairwise analysis, escalation was higher with chest tube plus fibrinolytics than with VATS, with a relative risk of 3.18 (95% CI 1.45 to 6.96).

The sensitivity analysis restricted to primary-line arms preserved these associations, but a higher network mortality estimate with thoracotomy lost statistical significance, suggesting that this finding was sensitive to how treatment lines were defined. Exploratory mean P-scores ranked VATS highest at 0.74, followed by thoracotomy at 0.50, chest tube plus fibrinolytics at 0.47, and chest tube alone at 0.29. These rankings, however, are exploratory summaries of the network rather than definitive statements about which treatment should come first in clinical practice.

The authors conclude that chest tube drainage alone was associated with more escalation than each alternative, while VATS was associated with shorter treatment-related durations. But they emphasize that the evidence is predominantly observational and of low to very low certainty for most comparisons, and that estimates involving thoracotomy were sensitive to treatment line. The associations are described as hypothesis-generating and do not establish a treatment hierarchy.

According to the review, trials with explicit disease staging and standardized definitions of treatment escalation are needed before firm conclusions can be drawn about the optimal strategy for children with this serious pneumonia complication.

Subject of Research: Comparative effectiveness of chest tube, fibrinolytics, VATS and thoracotomy for pediatric empyema thoracis

Article Title: Comparative effectiveness of treatment strategies for pediatric empyema thoracis: a systematic review with pairwise and network meta-analyses

Article References: Alhusami, M. A., Senjab, K., Alabdullah, M., Malik, M., Kanj, S., Kanj, L., & Naji, H. (2026). Comparative effectiveness of treatment strategies for pediatric empyema thoracis: a systematic review with pairwise and network meta-analyses. Frontiers in Pediatrics, 14, Article 1980275. https://doi.org/10.3389/fped.2026.1980275

Image Credits: AI Generated

DOI: 10.3389/fped.2026.1980275

Keywords: pediatric empyema, systematic review, network meta-analysis, VATS, chest tube drainage, intrapleural fibrinolysis, thoracotomy, treatment escalation, hospital length of stay, GRADE certainty, Comparative, effectiveness