Behandlung des Pleuraempyems

Pleural empyema remains a frequently encountered clinical problem and is responsible for significant morbidity and mortality worldwide. Its diagnosis may be difficult; delays in diagnosis and treatment may contribute to morbidity, complications, and mortality. The management of parapneumonic effusion and empyema depends on timely, stage-dependent therapy and the underlying etiology. Thoracentesis and antibiotics remain the cornerstones of treatment in stage I disease. In the early fibrinopurulent phase (stage II) thoracoscopic methods should be considered. As treatment strategy for this stage, fibrinopurulent pleural empyema entails thorough debridement of multiloculated collections from the pleural cavity by video-assisted thoracic surgery. After evacuation of multilocular effusions and the removal of fibrin deposits with drainage by two intercostal chest tubes, irrigation treatment helps to achieve clarity of the pleural discharge. Open thoracotomy and decortication are reserved for organized, multiloculated empyema with lung entrapment (stage III disease). Early drain removal may lead to rapid symptomatic recovery and complete resolution.     

Video-thoracoscopic and open surgical management of thoracic empyema

PURPOSE: To evaluate the outcomes of video-thoracoscopic and open surgical management of patients with thoracic empyema. METHODS: We studied 122 patients retrospectively who underwent surgery for thoracic empyema in our hospital between January, 1999 and January, 2005. Patients' medical records, surgical procedures, and outcomes were reviewed. The study identified 97 affected men and 25 affected women with a mean age of 54 years (range 16-78 years). The empyema was parapneumonic in 95 patients (78%). RESULTS: Forty-four patients who had stage II empyema underwent video-assisted thoracic surgery (VATS). The procedure was converted to thoracotomy in 13 patients (29.5%); the morbidity and mortality rates of VATS were 13% and 0, respectively. Seventy-eight patients had stage III empyema and, along with those 13 who were converted, underwent thoracotomy for decortication. The associated morbidity rate was 12%, and the mortality rate was 6.6%. Thoracotomy was considered successful in 90 of 91 patients (99%); one patient needed a reoperative thoracotomy for an organ space/surgical site infection with pus in the pleural cavity. CONCLUSIONS: Many treatment modalities are available for thoracic empyema, depending on the results of appropriate clinical and laboratory investigations. In fibrinopurulent empyema, VATS debridement is safe and effective, with minimal morbidity and no deaths. Lung decortication via thoracotomy is the only option for organized empyema and is associated with a substantial mortality rate.     

Video-assisted thoracoscopic surgery for children with stage II empyema

Children with stage II empyema often fail traditional medical management, frequently succumbing to the effective albeit morbid clutches of thoracotomy. Video-assisted thoracoscopic surgery (VATS) has been recently introduced as a viable and potentially less morbid alternative to open thoracotomy. We review our VATS experience in children with empyema, assessing surgical outcome. Between August 1996 and March 1999, 13 patients at our institution with stage II empyema that did not respond to conventional medical management underwent a modified VATS with decortication. Data from retrospective chart review reflects intraoperative findings and postoperative course, including average time to defervescence, removal of thoracostomy tube, and hospital discharge. VATS was completed in all 13 patients. All intraoperative cultures of pleural fluid and fibrinopurulent debris obtained at VATS showed no growth. The average time to defervescence was 2.2 days (range, 0-4 days) and to removal of thoracostomy tube 3.6 days (range, 2-5 days). Average total chest tube days in patients with pre-VATS thoracostomy (n = 6) was 14.5 days (range, 8-37 days) versus 3.1 days (range, 2-5 days) in patients (n = 7) who underwent primary VATS (t test, p < 0.05). The average time to surgical discharge after VATS was 5.8 days (range, 3 to 19 days). All patients were well on follow-up clinic visits without delayed complications. VATS can be performed safely and effectively in children with stage II empyema, thus avoiding the morbidity of open thoracotomy and decortication. Importantly, early application of VATS significantly relieves patients of unnecessary days of thoracostomy drainage.     

Video-assisted evacuation of empyema is the preferred procedure for management of pleural space infections

BACKGROUND: Empyema remains a cause of morbidity and mortality. Thoracoscopy has proved its versatility in the management of pleural space disorders. The suitability of video-assisted thoracic surgery (VATS) for decortication in the management of the fibrotic stage of empyema is unclear. METHODS: VATS evacuation of empyema and decortication was performed on seventeen patients presenting with pleural space infections. A retrospective review was performed and constitutes the basis of this report. RESULTS: VATS evacuation of empyema and decortication was successfully performed in 13 of 17 patients. Blood loss was 325 +/- 331 cc. Mean hospital stay was 18 +/- 10 days. Postoperative hospitalization was 11 +/- 7 days. Chest tubes remained in place for 7 +/- 3 days. There were no operative mortalities. CONCLUSIONS: Video-assisted evacuation of empyema and decortication is an effective modality in the management of the exudative and fibrinopurulent stages of empyema. An organized empyema should be approached thoracoscopically, but may require open decortication.     

Surgical therapy of pleural empyema

In the period from January 1976 to December 1986, 31 (56.3%) out of 55 patients with pleural empyema were treated, after failure of conservative treatment with antibiotic drugs, pleural puncture and tube drainage. Twenty-two patients were submitted to a posterolateral thoracotomy with debridement in the early stage or decortication in the later stage of empyema thoracis. There was no relapse of empyema in this group, but 7 patients suffered from air leakage for 7 to 19 days (mean 12 days). One patient needed rethoracotomy after debridement for continuous bleeding. Nine patients were treated in a first step with limited thoracotomy in local anaesthesia with or without costotomy. There were 5 relapses of empyema in this group. The average time of hospitalization was for the debrided cases 13.6 days and for the decortication group 19.6 days. The conservatively treated group remained during 39.5 days in the hospital.     

Surgical strategy of complex empyema thoracis.

BACKGROUND: The optimal treatment of empyema thoracis has been widely debated. Proponents of pleural drainage alone, drainage plus fibrinolytic therapy, video-assisted thoracoscopic surgical (VATS) debridement, and open thoracotomy each champion the efficacy of their approach. METHODS: This study examines treatment of complex empyema thoracis between June 1, 1994, and April 30, 1997. Twenty-one men and 9 women underwent 30 drainage/decortication procedures (14 open thoracotomies and 16 VATS) in treatment of their disease. Effusion etiology was distributed as follows: infectious-14; neoplastic-associated-7; traumatic-3; other-6. RESULTS: The mean preoperative hospital stay was 14 +/- 8.8 days, (11.4 +/- 6.5 days for VATS vs 16.8 +/- 10.2 days for thoracotomy). Hospital stay from operation to discharge for thoracotomy patients was 10.0 -/+ 7.2 days (median 8.5 days) and for VATS patients 17.6 -/+ 16.8 days (median 11 days). These differences were not statistically significant. Duration of postoperative thoracostomy tube drainage was 8.3 -/+ 4.6 days for thoracotomy patients and 4.7 -/+ 2.8 days in the VATS group (p = 0.01). Operative time for the thoracotomy group was 125.0 -/+ 71.7 minutes, while the VATS group time was only 76.2 -/+ 30.7 minutes. Estimated blood loss for the thoracotomy group was 313.9 -/+ 254.0 milliliters and for the VATS group 131.6 -/+ 77.3 milliliters. Three of the 30 patients (10.0%) required prolonged ventilator support (>24 hours). Morbidity included one diaphragmatic laceration (VATS group) and one thoracic duct laceration (thoracotomy). Two VATS procedures (6.7%) required conversion to open thoracotomy for thorough decortication. CONCLUSIONS: The surgical approach to empyema thoracis is evolving. In the absence of comorbid factors, the significantly lower requirement for chest tube drainage time in the VATS patients suggests that this modality is an attractive alternative to thoracotomy in the treatment of complex empyema thoracis.     

Surgical treatment of metapneumonic pleural empyema

During a period of 13 years 54 patients have been treated for metapneumonic pleural empyema, namely 3 children (all boys), 31 men and 20 women. One patient was admitted in extremis heavily intoxicated after unsuccessful attempt at closed drainage. He died during thoracotomy for open drainage. All the remaining 53 patients were cured, 3 out of 18 by closed thoracostomy (Bülau), 12 out of 16 by open drainage and 37 by decortication which had to be combined with pulmonary resection 13 times. Local treatment of pleural empyema is aimed at the obliteration of the pleural space. This goal can best be accomplished: in the acute exudative stage of the disease (according to the American Thoracic Society) by closed thoracotomy, in the fibrino-purulent phase by open thoracotomy with rib resection and in the chronic organizing stage by decortication.     

Stage-adapted therapy of pleural empyema. Results during 1992-1998

Despite the decreasing number of patients suffering tuberculosis and the use of modern broad spectrum antibiotics the pleural empyema did not lose its relevance. The main reasons are increasing numbers of patients with drug and alcohol abuse or immunodeficiency of different causes. We retrospectively analysed the data of 73 patients treated of pleural empyema between 1992 and 1998. Considering the known stages of pleural empyema we present the corresponding therapeutic results. All patients classified as stage I were treated with a chest drain and cure was achieved in all of them (100%). The treatment for patients classified as stage II was different: 5 out of 32 were treated with a continuous irrigation and suction chest drain system. 18 patients first underwent thoracoscopy and were afterwards treated with a continuous irrigation and suction system. Another 9 patients primarily underwent an early open decortication. In 40% the treatment with the suction and irrigation system was successful. Using video-assisted thoracoscopy (VATS) cure was achieved in 94.4%, with open decortication in 100%. The preferred treatment of patients classified as stage III is the open decortication. After the first operation 80% (30 patients) were cured. 6 patients needed thoracoplastic procedures after the first intervention. No patient was discharged neither with a permanent chest drain nor a permanent thoracic window. With the results a cause dependent analysis of morbidity and mortality was done. The overall morbidity rate was 27.9% and the overall mortality 5.4%. The treatment of pleural empyema still remains to be problematic. Corresponding to our results pleural empyema classified as stage I is best treated with a simple chest tube. The video-assisted thoracoscopy (VATS) lacks of complications and is a very efficient method in treating stage II. The method of choice in stage III is the open decortication which in the case of a chronic and recurrent or persistent infection should be followed by a thoracoplastic procedure.     

Chronic postpneumonic pleural empyema: comparative merits of thoracoscopic versus open decortication

Objective: We seek to evaluate the comparative merits of thoracoscopic versus open decortication in the surgical management of patients with chronic postpneumonic pleural empyema. Methods: From January 1996 to December 2006, 308 patients (180 males, 128 females, mean age: 56.3 years, range: 17–82 years) with chronic postpneumonic pleural empyema underwent decortication after failure of conservative treatment. Results: Decortication was performed by open thoracotomy in 123 (39.9%) patients (OT) and by videothoracoscopy (VT) in 185 (60.1%). Mortality was 1.29% (4/308). Morbidity was 21.1% (65/308). At 6 months follow-up, three VT patients showed recurrent empyema and underwent re-do surgery by video-assisted-thoracoscopy (VATS) (one patient) or by thoracotomy (two patients). The videothoracoscopic approach showed statistically significant better results in terms of in-hospital postoperative (day 1 and day 7), pain (p < 0.0001), postoperative air leak (p = 0.004), operative time (p < 0.0001), hospital stay (p = 0.020) and time to return to work (p < 0.0001). The analysis of postoperative pain at 6 months follow-up showed no significant differences among the different groups. Conclusions: In the light of our experience, videothoracoscopic decortication appears to be the surgical treatment of choice for chronic postpneumonic pleural empyema even if a multicentric-randomised trial should be performed before videothoracoscopic decortication becomes the gold standard for the treatment of pleural empyema.     

Thoracoscopic decortication: a role for video-assisted surgery in chronic postpneumonic pleural empyema

Background. We evaluated a technique of video-assisted thoracoscopic (VAT) decortication of the visceral cortex to reexpand entrapped lung in cases of chronic postpneumonic pleural empyema.

Methods. A prospective cohort study of 48 consecutive patients with multiloculated postpneumonic pleural empyema in whom visceral pleural decortication was required was studied. The effect of VAT decortication on perioperative outcome and factors affecting its success were assessed.

Results. Before the introduction of VAT decortication 12 patients were treated by thoracotomy (group T). In the subsequent 36 patients VAT decortication was attempted with success in 21 (group VS) but lung expansion was not observed in 15 patients (group VF) who required thoracotomy. There was no difference in the age or sex distribution of the 3 groups. Operating time was significantly longer in group T than group VS, mean difference 30.3 minutes (p = 0.001) and postoperative hospital stay was longer in group T than group VS, mean difference 2.9 days (p = 0.004). The success of VAT decortication was not related to either the delay between onset of symptoms or hospital admission and surgery; indeed the operating time decreased with increasing preoperative delay. However, success was related to increasing operative experience (p = 0.001).

Conclusions. VAT decortication is a feasible new technique to achieve lung reexpansion in chronic postpneumonic pleural empyema and has perioperative benefits over thoracotomy.     

Experiences in stage-adapted therapy of pleural empyema]

INTRODUCTION: Up till now the phases adapted treatment of a pleural empyema unfortunately is still not obvious, but recently the operative spectrum has been widened in the field of video-assisted thoracoscopic surgery (VATS) of the pleural empyema. PATIENTS AND METHODS: In the present study we examined all our patients with a pleural empyema and we followed them for a postoperative period of 4 years analysing our therapy-efficacy and our treatment concept of pleural empyema. RESULTS: 52 out of 102 patients--who suffered from a pleural empyema in the last 10 years--were reexamined postoperatively. In 96% of the 102 cases we found a phase II-III empyema. Initially all patients were treated with a closed-chest-tube drainage, followed by an operation in 78%. In 6 cases a video-assisted-thoracoscopic evacuation of the cavity with an early decortication was performed. All the 52 patients who were treated in an early phase showed the best functional results 4 years later. CONCLUSION: Especially in phase III the open operative revision of a pleural empyema is the method of choice. In the fibrinopurulent phase the drainage therapy may be sufficient. If the empyema cavity is divided we recommend the early video-assisted-thoracoscopic revision of the thoracic empyema.     

Role of decortication in management of parapneumonic empyema thoracis in children

Background

Parapneumonic empyema thoracis is a rare complication of bacterial pneumonia in children that emencely increases the morbidity. Classically parepneumonic effusions are divided into three stages. Stage I or exudative stage, Stage II or fibrinopurulent stage and stage III or organised effusion stage. The present study was designed to highlight the role of open decortication by thoracotomy in cases of para-pneumonic empyema of stage II and stage III disease in children.

Methods

A prospective observational study was done on 31 children of less than 15 years of age, who presented with stage II and stage III parapneumonic empyema thoracis. They underwent decortication surgery through postero-lateral thoracotomy.

Results

Out of the 31 children included in this study, there were 21 boys (67.74 %) and 10 girls (32.26 %). The average duration of symptoms was 17.84 days. The mean duration of post-operative chest drain was 2.55 days. Staphylococcus aureus was the most frequently encountered organism isolated in culture of fibrino-purulent material from the pleural cavity in 12 cases (38.7 %). Mean duration of total hospital stay was 8.3 days.

Conclusion

Decortication by thoracotomy is a safe and effective approach for stage II & III parapneumonic empyema thoracis in children leading to early recovery and less hospital stay.     

Video-assisted thoracoscopic decortication for management of postpneumonic pleural empyema

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) for decortication or debridement in the management of empyema thoracis has increased the available treatment options but requires validation. We present and evaluate our technique and experience with thoracoscopic management of pleural empyema, irrespective of chronicity. METHODS: From May 1, 2000, to April 30, 2002, VATS debridement and decortication in 70 consecutive patients presenting with pleural space infections was performed with endoscopic shaver system. A retrospective review was performed and the effect of this technique on perioperative outcome was assessed. RESULTS: The VATS evacuation of infected pleural fluid and decortication was successfully performed in 65 of 70 patients. The mean duration of preoperative symptoms before referral was 23 +/- 1.8 days. The mean duration of hospitalization before transfer was 13.5 +/- 1.5 days. Blood loss was 330 +/- 200 mL. Intercostal drainage was required for 5 +/- 3 days. The postoperative hospital stay was 5 +/- 0.7 days. There were no operative mortalities. CONCLUSIONS: Video-assisted thoracoscopic decortication with endoshaver system is a simple and effective method in the management of the fibropurulent or organic pleural empyema.     

The controversial role of decortication in the management of pediatric empyema

Open surgical procedures for pleural empyema remain controversial in children. The pediatric literature generally recommends a prolonged trial of antibiotics and closed tube thoracostomy drainage. We report a favorable experience with a selective approach to open drainage in 22 children, many of whom had an empyema already organizing at admission. Open drainage was considered in children whose conditions failed to improve after 3 to 5 days of therapy with antibiotics and closed drainage. The method of drainage was selected according to the pathologic phase of the empyema: five children with fibrinopurulent empyema were successfully managed by limited decortication, and 17 with organizing empyema received decortication. Clinical improvement was usually dramatic; most of the children became afebrile by postoperative day 3 and were discharged by postoperative day 10. There were no deaths. Three children (14%) had complications of postoperative air leak or infection. Streptococcus pneumoniae (5) and Hemophilus influenzae (3) were the most common single pathogens. The presence of anaerobic bacteria in 8 of 22 children (36%) was associated with rapid organization of the empyema and the need for decortication. Decortication procedures have a low risk and are effective in children with empyema. They should be considered as definitive therapy, rather than as a last resort.     

Thoracoscopic debridement for acute pediatric empyema: efficacy of ultrasonic surgical device.

Few studies have examined thoracoscopic treatment for pediatric empyema. We encountered three children with thoracic empyema successfully treated by thoracoscopic debridement. Patients were a 3-year-old girl, a 17 month-old boy and a 13-year-old girl who developed thoracic empyema during therapy for pneumonia. We performed dissection and debridement under thoracoscopy and resolved fibrinopurulent collections using an ultrasonic surgical device in two cases to search the dissection plane while minimizing injury to the lung parenchyma. Ultrasonic surgical device (USUTM) is very useful for performing effective debridement and irrigation with minimal pleural damage. Thoracoscopic debridement performed early in the course of therapy is recommended even for acute pediatric empyema and could prevent the unnecessary open surgical intervention or decortication.     

Pleural empyema complicated by spontaneous pneumothorax treated with thoracoscopic debridement and pleural irrigation: case report

A 69-year-old man who had experienced spontaneous left pneumothorax one week previously was admitted to our hospital for the management of left empyema thoracis. Because the symptoms did not resolve with antibiotic therapy and chest tube drainage, thoracoscopic debridement and pleural irrigation were performed in the fibrinopurulent phase 4 days after admission. The postoperative course was uneventful. This procedure is minimally invasive and effective in the treatment of acute empyema.     

The role of early limited thoracotomy in the treatment of empyema

On the basis of clinical experience with 80 patients at Denver General Hospital from 1979 through 1984, we devised a three-part classification of empyema. Class I empyema (n = 12) is pleural effusion with pH less than 7.2 and with no bacteria. Patients with this type of empyema were treated with short-duration chest tubes. Further treatment was required in two of 12. There were no deaths. Class II (n = 28) is classic uniloculate empyema. Patients with this category of empyema were treated with chest tubes, with two deaths. Class III (n = 40) is complicated empyema, with multiple loculations. Tube thoracostomy failed more often than not; decortication was required in 10 of 18 patients treated with prolonged tube drainage. Limited thoracotomy for drainage and placement of tubes was done in 22 patients. Five required extension of the thoracotomy and decortication. All 22 had resolution of the empyema with no additional procedures. Limited thoracotomy immediately or during the first week of treatment is recommended for all multiloculated or complex empyemas.     

Suction drainage: a new approach to the treatment of empyema.

Thirteen patients with empyema thoracis were treated with a new suction drainage technique. The method entails passing a catheter into the empyema cavity under ultrasound guidance and using strong suction to drain loculated pus. Eight patients had no recurrence after a single treatment and one patient had no recurrence after two treatments. The procedure was a useful palliative measure in two patients with malignant disease who subsequently died. In one patient failure of the lung to expand after the procedure showed the need for thoracotomy. In one other patient the empyema recurred and decortication was required.     

Outcomes of Video-Assisted Thoracic Surgical Decortication in 274 Patients with Tuberculous Empyema

Objective: The present work aimed to retrospectively assess the outcomes associated with decortication by video-assisted thoracic surgery (VATS) in patients with tuberculous empyema.Methods: Patients (n = 274) who underwent decortication by VATS for surgical management of pleural empyema between January 2000 to 2010 were included. Pre-, intra-, and post-operative characteristics were observed for all patients, which were followed up for 12 months to evaluate surgical outcomes such as postoperative complications and disease recurrence.Results: No patients required conversion to thoracotomy, and no death or postoperative bleeding was reported. The mean operation time was 104.5 ± 20.4 min, with 271.5 ± 41.3 ml intraoperative blood loss and median length of hospital stay of 7.2 ± 3.4 days. Of the 274 patients, 262 were followed up for 12 months; 26 (9.9%) patients showed complications, including incomplete lung re-expansion (11 patients) and persistent air leak (6 patients). While early disease recurrence was observed in 3 (1.1%) patients after surgery, late recurrence was reported for 6 (2.3%) individuals. Interestingly, the complication rate was much higher in patients with chronic empyema (15/34, 44.1%) than in subjects with acute empyema (11/228, 4.8%).Conclusions: Decortication by VATS decreases postsurgical complications, and results in decreased disease recurrence. This study demonstrated improved outcomes by decortication by VATS, even in patients with stage III tuberculous empyema.     

Ultrasonic pleural debridement of empyema.

Thoracic decortication is a common procedure for empyema. However, effective dissection without injuring the lung parenchyma is sometimes difficult. We introduce a new technique using an ultrasonic surgical unit (USUTM) to search the dissection plane and simultaneously perform pleural debridement and irrigation with minimal injury of the lung parenchyma. USUTM was used on 5 patients with acute empyema with fibrino-purulent phase and good clinical course was achieved. This procedure facilitates effective pleural debridement under either thoracoscopy or conventional thoracotomy.