CASE REPORT S. Sivasubramanian Æ V. Hjortdal Æ G. A. Cohen Synchronous bilateral VATS decortication for paediatric bilateral empyema Accepted: 4 March 2003 / Published online: 17 June 2004 Ó Springer-Verlag 2004 Abstract Bilateral empyema is a rare condition in children. In the current era of minimally invasive sur- gical treatment, our experience with two cases suggests that video thoracoscopic drainage and decortication for children with bilateral empyema is safe, effective, and potentially less expensive. Keywords Paediatric empyema thoracis Æ Thoracoscopic decortication Introduction Bilateral empyema thoracis is an uncommon condition in the paediatric age group. Of 87 patients presenting with empyema at our institution over the past 10 years, only three had bilateral empyemas. We describe our recent experience with two children treated for bilateral empyema thoracis using thoraco- scopic drainage with decortication, and we review the literature on this condition. Case 1 A 15 year-old male presented with a 5-day history of cough, blood-stained sputum, intermittent fever, and shortness of breath. A diagnosis of bilateral pneumonia and pleural effusions was made, and intravenous anti- biotic treatment was begun. When his clinical condition worsened, with acute renal failure and thrombocytope- nia, a pleural needle aspiration was done. The aspirate was clear, had pus cells but no organisms, and was culture-negative. Blood cultures drawn at the time grew Strep. milleri. A computed tomography (CT) scan of the thorax revealed large bilateral pleural effusions (Fig. 1), collapse of the lung bases, and multiple small noncavi- tating peripheral lung nodules (presumably abscesses or septic emboli). An echocardiogram was normal, and no signs of pelvic inflammation or intravenous drug abuse were detected. Because the patient’s clinical condition remained poor, surgery was planned, and sequential bilateral thoracoscopic decortication of the empyema was carried out. The patient was anaesthetised using fentanyl and propofol, intubated in the main stem, and maintained on isoflurane. He was first positioned in the lateral decub- itus position with his left side up and subsequently was turned over to the lateral decubitus position with his right side up. Almost 1.5 l of purulent fluid were drained from each pleural space, dense fibrinous adhesions were released, and thin pleural peel was removed piecemeal from both lung surfaces. The lungs were confirmed to have expanded fully with no significant air leak or bleeding. The patient’s postoperative recovery was dramatic. He was alert, comfortable, and afebrile within hours and was extubated within 10 hours. Chest tube drainage re- mained significant for 4–5 days but then decreased. The entire postoperative course was smooth and uneventful except for occasional spikes of high temperature that were self-limiting and controlled with antipyretic medi- cation. One drain was removed on the 7th day, but the other could only be taken out after 15 days. Case 2 A 12-year-old female had been unwell for 10 days with high fever, nonproductive cough, and left-sided pleuritic S. Sivasubramanian Æ V. Hjortdal Æ G. A. Cohen Cardiothoracic Unit, Great Ormond Street Hospital for Children NHS Trust and the Institute of Child Health, London, UK G. A. Cohen (&) Cardiothoracic Unit, Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London, WC1N 3JH, UK E-mail: gordon.cohen@seattlechildrens.org Tel.: +44-20-74059200 ext. 5416 Fax: +44-20-78138262 Pediatr Surg Int (2004) 20: 469–471 DOI 10.1007/s00383-004-1180-0