Study objectives: To determine the optimal treatment of empyema thorac
is (within the fibrinopurulent phase of illness) comparing pleural dra
inage and fibrinolytic therapy vs video-assisted thoracoscopic surgery
(VATS), with regard to efficacy and duration of hospitalization. Desi
gn: Twenty patients with confirmed parapneumonic empyema thoracis were
randomized to chest tube pleural drainage plus streptokinase (CT-SK)
vs VATS, Setting: University-based teaching hospital providing for Dal
las County. Patients and methods: Equivalent groups of patients with p
arapneumonic empyema thoracis were randomized to receive either of two
therapies: CT-SK (n = 9) or VATS (n = 11), Outcomes analysis with res
pect to treatment efficacy, hospital duration, chest tube duration, ho
spital costs, and need for subsequent procedures was performed. Result
s: Each group suffered one mortality (p = not significant), When compa
red with the CT-SE group, the VATS group had a significantly higher pr
imary treatment success [10/11, 91% vs 4/9, 44%; p < 0.05 Fisher's Exa
ct Test], lower chest tube duration (5.8 +/- 1.1 vs 9.8 +/- 1.3 clays;
p = 0.03), and lower number of total hospital days (8.7 +/- 0.9 vs 12
.8 +/- 1.1 days; p = 0.009), Clinically relevant but not statistically
significant differences in hospital costs ($16,642 +/- 2,841 vs $24,0
52 +/- 3,466, p = 0.11) also favored the VATS group. Of note, all the
CT-SK treatment failures could be salvaged with VATS, and none require
d thoracotomy. Conclusions: In patients with loculated, complex fibrin
opurulent parapneumonic empyema thoracis, a primary treatment strategy
of VATS is associated with a higher efficacy, shorter hospital durati
on, and less cost than a treatment strategy that utilizes catheter-dir
ected fibrinolytic therapy.